“Her death has become one of those major modern occasions where there seems to have been a collective sense of empathy for a stranger’s fate. She has become an embodiment of the betrayal, vulnerability and public abandonment of children. The inquiry must mark the end of child protection policy built on a hopeless process of child care tragedy, scandal, inquiry, findings, brief media interest and ad hoc political response”.1
Upon investigating the serious nature of this case and it’s deeply distressing facts it became apparent that Victoria’s ‘high media’ profiled incident exposed a clear lack of precision and communication between all professionals and agencies involved. The anguish and eventual murder of Victoria in 2000 from hypothermia, caused by malnourishment and damp conditions, provoked ‘the most extensive investigation into the child protection system in British history.’ 2 Throughout this essay, the health, safety and welfare policy and practice that came about after the Victoria Climbie case will be briefly reviewed and evaluated. On the evening of 24th February 2000, Victoria Adjo Climbié who had been born near Abidjan in the Ivory Coast just over eight years earlier – was admitted to the North Middlesex Hospital in London.
Many independent statutory reports described how Victoria was desperately ill: “she was severely bruised, physically deformed by repeated beatings, malnourished, and her core body temperature was so low it could not be recorded on the hospital’s standard thermometer”3 Despite extensive efforts by Dr Lesley Alsford and other medical professionals, Victoria’s condition continued to deteriorate. Victoria Climbié died in the intensive care unit of St Mary’s Hospital Paddington on 25 February 2000, aged 8 years and 3 months. Her death was caused by multiple injuries arising from months of ill-treatment and abuse by her great-aunt, Marie-Therese Kouao and her great-aunt’s partner, Carl John Manning.
Following their conviction for her murder, Lord Laming was appointed in April 2001 to chair an independent statutory inquiry into the circumstances leading to and surrounding the death of Victoria Climbié. Significantly it was further used to make recommendations “as to how such an event may, as
far as possible, be avoided in the future.”4 The main underpinnings of the investigation were of identifying what had happened throughout Victoria’s time in England and what mistakes were made by all professionals investigating the case. The ‘Laming’ inquiry (2003) gave a clear and concise account of Victoria’s mistreatment and failings as echoed by Peter Beresford’s quote at the front of this piece. It was apparent that suffering had gone unnoticed by the social services, police and NHS staff (twelve professional agencies in total), who failed to make each other aware of the clear danger signs.
The report made 108 sweeping recommendation about modifications that were needed in the child protection system as a response to the errors made by professionals who had accountability for Victoria’s care. Indeed within the ‘Laming Inquiry’, it was acknowledged that the key failings that underpinned the case of Victoria (and other child protection cases as is signified below) included: “inadequate resources to meet demands, poor communication, inexperience and a lack of skill of individual social workers”.5 These apparent failings however are not new to a modern day society. Through my research I have also discovered that 80 children (on average) die of abuse or neglect every year. Furthermore since 1948 there have been around 70 public inquiries into major cases of child abuse. The names of many of the children (like Victoria) have become case studies, simply because of the nature of their deaths.
The consistency and regularity of such appalling cases echoed by Victoria’s inexcusable treatment created growing pressure to deal with the inadequacies they had revealed in the ‘Laming Inquiry’. It was therefore recommended by Lord Laming that the Green Paper of ‘Every Child Matters’6 be introduced. This legislation created the platform for all children to have the fundamental right to be protected from harm and abuse. In addition to this: “Local bodies such as the police and health organisations will, subject to consultation, have a new duty to safeguard children, promote their well-being and work together through these partnership arrangements”.7 Cross-party support in both Houses of Parliament meant the Green Paper quickly became transformed into the Children’s Act of 2004. It was ‘one of the most significant changes in local children’s services in living memory’.8
The extensive details of the report are wide ranging and to extensive for this essay but the main priority of the green paper was to address that: “the services to children and families are properly co-ordinated and that the inter-agency dimension of this work is being managed effectively”.9 Government’s aim was simple: for every child, whatever their background or their circumstances, to have the support they need to: be healthy; stay safe; enjoy and achieve; make a positive contribution; achieve economic well being.10 These five outcomes have become the bedrock of the ‘Every Child Matters’ national framework. They have provided the necessary directives for a more extensive and effective child focused national strategy; where key organisations involved with providing services to children – from hospitals and schools, to police and voluntary groups work in collaboration, to protect children and young people from harm and help them achieve what they want in life. The Victoria Climbie case highlighted the fact that the multi-agency ‘structure’ was not as organised and effective as it should have been. The inquiry identified an absence of ‘basic’ practice as it can be seen that there was a number of key occasions where Victoria was recognised to be a child in need, but these opportunities for successful intervention were passed by.
Henceforth the passing of the Children’s Act of 2004 has allowed a legislative spine for the expansion of more effective, child focused services in which all professions and sectors have been unified in order to work more collaboratively around a preventative and early intervention agenda. A significant part of this ‘legislative’ spine was to therefore focus on the well-being of children and young people from birth to age 19 using the five outcomes as addressed above. A significant step in this ‘focus’ was the re-birth of ‘Multi –agency working ’where a more cohesive and streamlined structure has set about an effective way of addressing risks in vulnerable children. In the case of Victoria these risks failed to be identified. Through the emergence of ‘Every Child Matters’ it was hoped such obvious risks of vulnerability were identified with far more consistency and rapidity. *Fig 1.1- shows this more coherent ‘streamlined’ structure of multi agency working.11
The Children Act 2004 and Every Child Matters have therefore established a framework for every child and young person’s entitlement to make progress against the five outcomes. The Children’s Workforce Development Council (CWDC) suggests that in order to work successfully with children and young people, “it is important that everyone involved in the care of children and young people should be recruited with the intention that they follow [the training courses provided]”.12 The CWDC also explored the importance of communication (as discussed above) within multi-agency working, as well as how providing and presenting appropriate facts and judgements objectively will enable other practitioners and professionals to deliver early support where needed. This sort of communication it is clear to say was not apparent in Victoria’s case emphasising the CWDC clinical viewpoints on clear professional and social responsibilities when working with young children. Another aspect that has been developed and improved is the assessments that are undertaken when working with children and families. Laming identifies how there was no assessment of need made about Victoria despite the fact that she was seen and assessed by many professionals. Therefore, from Laming’s recommendations and subsequent to the Children Act in 2004 the ‘Common Assessment Framework’ (CAF) was established.
The CAF directly correlates to the five outcomes of’ Every Child Matters’: “It is a shared assessment and planning framework for use across all children’s services and all local areas in the UK. It helps to identify in the early stages, the child’s additional needs and promote coordinated service provision to meet them.”13 Following on from the emergence of CAF’s, and particularly as part of the strategy around ‘Every Child Matters’ and the Children Act, the government has looked to the extended schooling as a key expression of the ‘joined-up’ work of children’s services.14 The Minister for Extended and Inclusive Schools at the time, Catherine Ashton, argued that every school should become an extended school. She believes that “Extended services in schools can help improve pupil attainment, behaviour and motivation. They can help provide out of school study support to improve pupils’ learning”.15 Its immediate purpose was to open out to pupils, families and the wider community during and beyond the school day and in particular focus on vulnerable groups, in areas of deprivation and/or where services are limited. Its links to ‘Every Child Matters’ is evident through the clear association extended schools will have with parents, mental health services, family support links and child psychologists.
These links will shape the needs of a community and provide a better clarity of communication between vital services especially those dealing with vulnerable children. As can be seen from the development of the Children’s Act and its subsequent Every Child Matters agenda many legislative policies have been implemented to improve the services professional bodies offer to children between the ages of 0-19. The death or serious injury of a child seems to demand a response of structural change. However, as Action for Children (2010) suggests, although practice has undoubtedly improved, it can be seen that this change is more to do with the lessons of previous mistakes and the gaining of knowledge about child abuse than because of modifications to an existing structure. As discussed earlier, ‘The Laming Inquiry’ echoes the fact that currently in the UK around eighty children die every year from abuse or neglect which is evidence that structures within the system are still not quite right. Nevertheless, it can also be seen to demonstrate the fact that child deaths cannot be prevented. The Munro Review of Child Protection (2011) supports this as it suggests that the problem with safeguarding children it the fact that evidence of abuse or neglect are not clearly seen or labelled. It is therefore vital that continuing to improve links between professional child services (including hospitals and social services) as evident by the extended schooling agenda will help reduce this uneasy vague evidence to continuing child abuse in the UK.