The most disturbing reality about the Victoria Climbié case was that her death could have been prevented. She wasn’t hidden away but was known to several agencies empowered by Parliament to protect children which lead to the conclusion that her suffering and death was due to gross failure of the system which is inexcusable. Lord Laming and his colleagues identified 12 key occasion where relevant services had the opportunity to successfully intervene in the life of Victoria but hadn’t (Laming, 2003).
Victoria lived in England for eleven months and was initially known to Ealing Housing Department’s Homeless Persons’ Unit in April 1999 but following this she became known to two further housing authorities, four social services departments, two child protection teams of the Metropolitan Police Service, a specialist centre managed by the NSPCC and admitted to two different hospitals because of suspected deliberate harm but yet no-one recognised the danger she was in and took any appropriate and successful action to prevent her death (Laming, 2003).
Lord Laming reported that “even after listening to all the evidence, I remain amazed that nobody in any of the key agencies had the presence of mind to follow what are relatively straightforward procedures on how to respond to a child about whom there is concern of deliberate harm” (Laming, 2003, pg. 4). He came to the conclusion that the statutory framework for child protection set out in the Children Act 1989 is basically sound but as Alan Milburn said in his statement on the Laming Report “Sound legislative policy and guidance is frankly useless unless we can be sure that it is implemented effectively and consistently” (Guardian, 2003).
If only staff had been aware of policies and procedures and had followed them, such a tragedy might have been averted. It appears that basic good practice was absent.
Lord Laming also reported that although it appeared that a number of junior staff from Haringey Social Services were suspended and faced disciplinary action, the more senior staff were left alone and appointed to other, presumably better paid jobs which is not a good example of managerial accountability. Management should be aware of the work going on involving their front-line staff and be accountable for it. As a result of these findings Lord Laming believed that “in future, those who occupy senior positions in the public sector must be required to account for any failure to protect vulnerable children from deliberate harm or exploitation” (Laming, 2003, pg. 5).
Shortly after the Laming report was published the Guardian reported that it exposed a breakdown in the multi-agency child protection system established in the wake of the murder of seven-year-old Maria Colwell in 1973. Health, police, housing charities and social services failed to work together to protect Victoria. The Laming report concluded that the child protection system failed as a result of a lamentable lack of basic good practice by frontline staff and, most significantly, senior managers failing to take responsibility for the failings of organisations (Guardian, 2003).
Social work is extremely complex. Child protection work inevitably involves uncertainty, ambiguity and fallibility. The knowledge base is limited, predictions about the child’s future welfare are imperfect, and there is no definitive way of balancing the conflicting rights of parents and children. The public rightly expect high standards from child protection workers in safeguarding children but achieving them is proving problematic (Munro, 2002).
The final submission to the 1988 Cleveland inquiry of the Social Services Department point out “The Social Services, of course, always have a thankless task. If they are overcautious and take children away from their families they are pilloried for doing so. If they do not take such action and something terrible happens to the child, then likewise they are pilloried” (DOH, 1991). I believe this is partly true but still in this particular case there were just too many occasions when the professionals involved should have had serious alarm bells ringing and acted appropriately in the best interests of Victoria. It was just too obvious that there was something seriously wrong.
I think it is important to now identify what the agencies involved could have done differently to protect Victoria.
It was on the day of Victoria’s second visit to hospital that the senior house officer who first examined Victoria explained the position to Haringey Social Services. A detailed referral was made three days later by an Enfield social worker based at the hospital resulting in a strategy meeting at Haringey’s offices on 28 July 1999 when Victoria’s case was allocated to social worker Lisa Arthurworrey (Laming, 2003). Lisa Arthuworrey, along with PC Karen Jones, visited Victoria in hospital on 6 August and after briefly speaking to her decided it would be appropriate for her to be discharged back into Kouao’s care. I find this particularly astonishing as so many of the medical staff who came into contact with Victoria during her stay in hospital had noticed various marks and bruising over her body. Also, Victoria spoke very little English so an interpreter should have been present which could have been all it took to realise the extent of abuse she was suffering. It is surprising that this was considered not to be of importance given the situation.
The Laming report identified problems with managerial accountability. If the managers of the relevant agencies were properly overlooking what was going on in their agency they would have been able to assist perhaps more inexperienced members of staff to act appropriately and successfully to protect Victoria.
Victoria was just Eight years three months old when she died and it was on this day that Haringey Social Services formally closed the case prior to hearing the news of her death. This is shocking due to everything that had happened. I think this really opens up the need for the sharing of information between agencies. If all the agencies involved communicated and knew what had gone on every step of the way then the seriousness of the situation would surely have come to light and something would have been done and it would not have resulted in Victoria’s death.
Victoria was of school age but did not attend school in England. I think if the social worker alerted the education authorities who would have arranged her schooling this would have assisted Victoria’s English language development and may have helped in identifying the abuse she was being subjected to. It would also have given Victoria time away from poor living conditions and the abusive environment.
Victoria was presented as Kouao’s daughter although they did not look particularly alike. I think there is a problem with asking sensitive questions, regarding skin colour for instance, through fear of being accused racist. In Victoria’s case I think this fear affected professional practice and stopped people acting. If people asked important questions that they should have done, this may have opened up what was really going on. I think social workers need to be trained in anti-oppressive practice and be prepared to work with people from diverse backgrounds and work on dispelling their own prejudices and stereotypes. This will ensure that all social work staff are trained to be confident and competent when working with minority ethic children and families.
Lord Laming presented a total of 108 recommendations for the future, 46 of which should be implemented within three months, 36 within six months and the remaining 26 within two years. They are formed under the headings of General, Social care, Healthcare and Police (Laming, 2003).
Victoria’s case affected the whole country and is definitely an issue to be addressed on a national level as if this poor professional behaviour was happening in one area, it could well be happing in another part of the country.
I will now look at how practice has developed since the Laming report was published in response to the recommendations put forward in the report.
On 19 May 2003, six Government departments issued a booklet called “What To Do If You’re Worried A Child Is Being Abused” which communicates directly with people working with children and families and explains their role in the safeguarding process. This role is set out in existing Government guidance “Working Together to Safeguard Children” and “The Framework for the Assessment of Children in Need and their Families”. The booklet is designed to protect children more effectively through a better understanding of what to do about any concerns (National Council of Voluntary Child Care Organisations, 2003).
The Green Paper “Every Child Matters”, which was published on 1 September 2003, constituted the Government’s policy response to the findings and recommendations of Lord Laming’s Inquiry although they are keen to stress that it aims to provide more than just a response. It aims to address child protection in a broader context of earlier intervention and the roll-out of better preventative services. It was published as a Green Paper for consultation on 8 September 2003, concurrently with the Government’s recommendation-by-recommendation response to Lord Laming’s report. Consultation on the original Green Paper indicated broad support for its aims and objectives. Its proposals have since been further developed in subsequent documents including Every Child Matters; Next Steps and Every Child Matters; Change for Children. In tandem, the Department of Health has prepared the National Service Framework for Children, Young People and Maternity Services which sets standards for children’s health and social services, and the interface of those services with education (The United Kingdom Parliament, 2005).
Many reforms proposed in Every Child Matters – including the establishment of a Children’s Commissioner for England – required amendments to statute. Consequently, a Children Bill was presented to Parliament in March 2004 and subsequently received royal assent on 15 November 2004. The Children Act 2004, as it now is, provides the legal ‘backbone’ for the programme of reform (The United Kingdom Parliament, 2005).
The Guardian reported that at the national level, a new agency for children and families, whose chief executive would be like a children’s commissioner, would advise government on the impact of proposed policies and scrutinise legislation, as well as reviewing serious child abuse cases (Guardian, 2003). This addresses the managerial problems identified in the Laming report by regulating the whole system.
Other major recommendations, the Guardian reported, include setting up a national database that records every contact every child under 16 has with the police, health and local authority services to prevent them from getting lost in the system (Guardian, 2003). This addresses the problems regarding the history of an individual and sharing of information between agencies.
The framework for social work training has also developed quite substantially. The two year Diploma has now been replaced with a three year degree. The degree has been introduced to encompass greater practical experience and to improve the skills base and competence of newly qualified social workers. The Chief Executive of the General Social Care Council (GSCC), Lynne Berry, said “good quality service starts with good quality training. The GSCC are working with universities to ensure that tomorrow’s social workers are clear about the standards they are expected to meet, inspire public confidence in social care and are able to work successfully with colleagues from other professions. The new degree will ensure that newly qualified social workers have all the skills they need to begin successful careers” (GSCC, 2003).
In addition to the new training framework, the GSCC now have a code of practice for social workers and employers which explicitly address some of the mistakes and problems that happened in Victoria’s case and others before it. A social care register has also been introduced which records all social care staff. Any workers who breach the codes of practice could be removed from the register. In this way, anyone found to be unsuitable would be prevented from working in social care (GSCC, 2003).
In summary, I have looked at the background of Victoria’s life leading up to her death and then looked at what the Laming report found went wrong in this case which showed incredible unprofessional practice. It discovered that the problem was not specifically the policies and procedures but it was the implementation of these and managerial accountability. I have then made suggestions about what the agencies could have done differently to protect Victoria. Finally, I looked at how the recommendations from the Laming report have been put into practice in relation to general national and social care changes to show how practice has developed over time.
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