Public Inquiry: Victoria Climbié (2003)

Who led the inquiry: Lord Laming

Local authority: Haringey

What happened?

In 1998, Victoria Climbié’s parents entrusted her to the care of her great aunt, Maria-Theresa Kouao who lived in Paris. Her time in Paris was short lived though, as Kouao was wanted by French authorities over benefit payments. Victoria was taken to London to live in a hostel, initially, before moving to Tottenham with her aunt to stay with Karl Manning in 1999. Between July 1999 and February 2000, Victoria experienced horrendous incidences of abuse and torture. Despite multiple visits to Central Middlesex Hospital and alerts made to child protection authorities, interventions were insufficient and contributed to Victoria’s death on 25 February 2000. Victoria died with a total of 128 separate injuries on her body. On January 2001, Victoria’s great aunt and Manning were convicted of her murder.

Why was the inquiry setup?

The purpose of the inquiry was to find out why Victoria was subjected to ongoing cruelty without appropriate interventions to protect her.

Findings

• Lack of professional curiosity: Social worker called at Victoria’s home several times, though got no reply so assumed they had moved away. This illustrates a lack of professional curiosity.
• Lack of multi-agency working: Victoria was known to three housing authorities, four social services departments, two child protection teams of the Metropolitan Police Service (MPS), a specialist centre managed by the NSPCC and was admitted to two different hospitals because of suspected and deliberate harm. Tragically, Haringey Social Services closed her case on the day she died highlighting a lack of vigilance and due diligence to protect Victoria across all agencies.
• Poor staffing levels and leadership: All agencies who knew Victoria were accused of giving low priority to child protection, reflecting underfunding, poor staffing levels and poor leadership.

Impacts on practice

• Publication of ‘Every Child Matters’ (2003) and passing of the Children Act 2004, supporting the formation of child protection plans and creation of an integrated children’s computer system (ICS) to assist in the collection of evidence.
• Creation of the post of Director of Children’s Services in each council who is accountable for the safety of all children in their area.
• Common Assessment Framework (CAF) established to support partnership working across agencies.
• Establishment of Local Safeguarding Children Boards (now replaced by Local Safeguarding Children Partnerships) to take responsibility for multi-agency child protection training and investigating the causes of deaths and incidents of serious harm, which could have been preventable.