‘We Said Never Again After Climbié. We Were Wrong’
Lord Laming, the child protection expert who led the inquiry into the circumstances of the killing of Victoria Climbié in Haringey in 2000, spoke of his distress that the same north London borough should have been the setting for the death of another child known to welfare and health agencies, despite the reforms that followed his investigation.
“What I had hoped was that Haringey would develop services that would make it an exemplar of good practice,” Laming said last night. “Although our recommendations were not directed only at Haringey – they were directed nationally to all the services – I had hoped they would be a sufficient stimulus for Haringey to say ‘never again’.”
The outcome of the Baby P case will prompt questions about the value of the post-Climbié reforms, which aimed to improve multi-disciplinary support for children at risk by creating children’s services departments in local councils and children’s trusts bringing together professionals from different agencies.
The value of children’s trusts was queried in a report by the Audit Commission last month which said their role was unclear and confusing. The effectiveness of separate children’s services departments has also been challenged: one in 10 councils have either kept or reverted to a single organisational structure for children’s services in order to maintain a holistic view of a family’s needs.
But the fundamental principle of reorganising professionals around the child is seen by most as sound: Laming described the government’s Every Child Matters response to his report as “an outstanding statement of policy” and the commission also acknowledged that collaborative working had improved.
Unlike Climbié, Baby P was not a victim of the agencies responsible for children’s welfare failing to talk to each other. An independent review of the case, published yesterday by Haringey’s local safeguarding children board, found “clear evidence of appropriate communication between and within agencies”. It said there were sometimes weaknesses in the flow of information between individuals, but the administrative framework was sound.
What the Baby P case calls into question is individual practice. The review found the biggest mistake was made three days before the toddler died when a paediatrician failed to identify his probably fractured ribs and broken spine. It said: “A diagnosis of abuse should have been made at that point.”
It added: “Many factors contributed to the inability of the agencies to understand what was happening [to the child.] With the possible exception of the paediatric assessment, none on their own were likely to have enabled further responses that might have prevented the tragic outcome.”
But the case demonstrated a reticence among care professionals to investigate, question and challenge.
Harry Ferguson, professor of social work at the University of the West of England, said: “The striking thing for me is how the social workers failed to touch the child, to examine him, and the skillful deceit by the mother and cohabitants to conceal the injuries … I think it exposes structural weaknesses in how we are failing to prepare professionals.”
Emphasising that he had not followed the Baby P case in detail, Laming said: “People who do deliberate harm to a child often go to great lengths to disguise what they have done … People who work in this field have to recognise this in their evidence gathering. They have to be sceptical; they have to be streetwise; they have to be courageous.”
Background: The death of Victoria Climbié
Victoria Climbié, who was born in Ivory Coast, died in Haringey in north London in February 2000 at the age of eight. She died from hypothermia caused by malnourishment and damp conditions, and a postmortem found that she had 128 injuries. She had been the victim of sustained abuse by her great-aunt, Marie Therese Kouao, and Kouao’s boyfriend, Carl Manning.
There was a public inquiry, chaired by a former chief inspector of social services, Lord Laming. It found that the abuse went undetected by social services, police and NHS staff, who failed to alert each other to obvious danger signs. Laming concluded she had been “treated worse than a dog”. In response, the government ordered the integration of children’s services into local children’s trusts.