Murder of Victoria Climbié 617683 222388445 2008-06-29T02:25:37Z 71.63.15.156 /* Abuse */ {{Infobox Person |name=Victoria Climbié |image= |caption= |birth_date=[[2 November]] [[1991]] |birth_place=[[Abobo, Abidjan|Abobo]], [[Côte d'Ivoire|Ivory Coast]] |death_date=[[25 February]], [[2000]] (age 8) |death_place=[[London]], [[England]] (severe physical abuse) |parents=Francis Climbié and Berthe Amoissi }} '''Victoria Adjo Climbié''' ([[2 November]] [[1991]]–[[20 February]] [[2000]]) was [[child abuse|abused]] and [[child murder|murdered]] by her [[legal guardian|guardians]] in [[London]], [[England]], in 2000. The public outrage at her death led to a [[public inquiry]] which produced major changes in [[child welfare|child protection]] policies in the [[United Kingdom]], including the formation of the [[Every Child Matters]] programme; the introduction of the [[Children Act 2004]]; the creation of the [[ContactPoint]] project, a planned [[government database]] that will hold information on all children in [[England and Wales]]; and the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner.<ref>[http://news.bbc.co.uk/1/hi/programmes/breakfast/3089072.stm BBC News]</ref> Both her guardians, Marie-Thérèse Kouao (born [[18 July]] [[1956]] in Bonoua, Ivory Coast) and Carl Manning (born [[31 October]] [[1972]]), were convicted of [[murder]] and sentenced to [[life imprisonment]] at their trial on [[12 January]] [[2001]].<ref>[http://www.bernardomahoney.com/forthcb/pdt/articles/capgoam.shtml Future Books - " Flowers in Gods Garden " - Articles - 12/01/01 - Child abuse pair guilty of Anna murder<!-- Bot generated title -->]</ref> Born in Abobo, [[Côte d'Ivoire|Ivory Coast]], Climbié moved to England at the age of seven with her great-aunt Kouao. It is suspected that Kouao started abusing Climbié soon after her arrival in the country, and the abuse worsened when Kouao moved in with Carl Manning. Up to her death, the [[police]], the [[social work|social services]] department of many [[local government in the United Kingdom|local authorities]], the [[National Health Service]], the [[National Society for the Prevention of Cruelty to Children|NSPCC]], and local churches all had contact with her, and noted the signs of abuse. However, in what the judge in the trial following Victoria's death described as "blinding incompetence", all failed to properly investigate the abuse and little action was taken. She died in February 2000, aged eight. == Abuse == Victoria Climbié was born in Abobo near [[Abidjan]], [[Côte d'Ivoire|Ivory Coast]], the fifth of seven children. At the age of seven, she was sent by her parents, Francis Climbié and Berthe Amoissi, to Europe with her great-aunt Marie-Thérèse Kouao for a chance of an education; this sort of informal [[fosterage]] is common in [[West Africa]]<ref>[http://www.blackwell-synergy.com/doi/abs/10.1046/j.1365-2214.2000.00155.x?cookieSet=1&journalCode=cch B Olusanya, D Hodes (2000) ''West African children in private foster care in City and Hackney'' "Child: Care, Health and Development",] 26 (4) , 337–342 </ref>. She travelled on a false passport in the name of Anna Kouao, a person not related to Marie-Thérèse Kouao but born roughly the same time as Victoria.<ref>[http://www.victoria-climbie-inquiry.org.uk/Background/back_chron.htm Victoria Climbie Inquiry - Background - Chronology], The Victoria Climbié Inquiry. Retrieved on [[5 July]] [[2007]].</ref> Victoria was known as ''Anna'' throughout her life in England.<ref>"[http://news.bbc.co.uk/1/hi/uk/1568586.stm Father's tears over Climbie photo]", BBC, [[28 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Before taking Victoria, Kouao lived in France with her three sons, claiming [[welfare (financial aid)|welfare benefits]].<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 25: 3.7, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Her ex-husband died in 1995. She went to the Ivory Coast to attend a funeral, and told Victoria's parents that she would like to take a child with her back to France to give them the chance of a better life. Victoria was chosen as she was regarded as the most promising. Victoria's parents had only met Kouao a few times, though they were satisfied with the arrangements. It is not known exactly when Kouao started abusing Victoria. Victoria's parents received three messages about her from the time of leaving to her death, all saying she was in good health. Victoria left the Ivory Coast with Kouao "probably some time in November 1998"<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 26: 3.6, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> and travelled to [[Paris]], [[France]], where she enrolled at school. By December 1998, however, Kouao began to receive warnings about Victoria's [[absenteeism]], and in February 1999, the school issued a child-at-risk notification and a [[social work]]er became involved. The school noted how Victoria tended to fall asleep in class, and the headteacher later recalled Kouao mentioning Victoria suffering from some form of [[dermatology|dermatological]] condition and that, on her last visit to the school on [[25 March]] [[1999]], Victoria had a shaven head and was wearing a wig.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], pp. 25–26: 3.7–3.11 [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> When they left France, Kouao owed the authorities [[pound sterling|£]]2000, after being wrongly paid in [[child benefit]], and it is claimed that Kouao viewed Victoria as a useful tool for claiming benefits.<ref name="life of horror">"[http://news.bbc.co.uk/1/hi/uk/1102191.stm Victoria's life of horror]", BBC, [[12 January]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> They travelled to [[London]], [[England]], on [[24 April]] [[1999]], to the [[London Borough of Ealing|Ealing district]]. Between [[26 April]] [[1999]] and [[7 July]] [[1999]], Kouao visited Ealing social services fourteen times for housing and financial purposes. Victoria was with her on seven occasions. The staff there noticed Victoria's injuries, with one staff member thinking that she looked like a child from an "[[ActionAid]] poster", but they did not take any action and may have presumed that Victoria's appearance was a purposeful attempt to elicit sympathy.<ref name="twelve"/> They lived in a [[bed and breakfast]] in Ealing until [[1 May]] [[1999]], before moving to [[Harlesden]], in the [[London Borough of Brent|Brent district]]. Kouao got a job as a hospital cleaner, leaving Climbié to the care of a [[nanny|childminder]], Priscilla Cameron, who was unregistered, which the social services did not check. On [[14 June]] [[1999]], Kouao met Carl Manning, a [[Ghana]]ian, on a bus which he was driving, and she and Victoria moved into his one-bedroom flat in [[Tottenham]], in the [[London Borough of Haringey|Haringey district]], on [[6 July]] [[1999]]. She was his first girlfriend.<ref name="life of horror"/> Victoria was abused by both Kouao and Manning, and it is suspected that the abuse got worse from then on.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 28: 3.29, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> On [[18 June]] [[1999]], a woman related to Kouao anonymously telephoned Brent council and told a customer services officer about Victoria's injuries and said that she feared for the girl's life. She rang again a few days later, and was given the impression they were onto the case.<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/sep.htm#28SEP01 Witnesses to be Called in Week Beginning 1 October]", The Victoria Climbié Inquiry, [[28 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://news.bbc.co.uk/1/hi/uk/1574093.stm Victoria's relative 'warned social services']", BBC, [[1 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,561467,00.html Social services were told Victoria's life was in danger]", ''The Guardian'', [[1 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Three weeks later on [[14 July]] [[1999]], social workers from the council visited Victoria's address, but it was empty and no further action was taken.<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/oct.htm#12OCT01 Witnesses to be Called in Week Beginning 15 October]", The Victoria Climbié Inquiry, [[12 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="twelve">"[http://news.bbc.co.uk/1/hi/uk/2122256.stm Could Victoria have been saved?]", BBC, [[11 July]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> In the inquiry following Victoria's death, Edward Armstrong, a senior social worker at the council, said that the team were told that a child was not in school, and not that a child was being abused.<ref name="twelve"/> === First hospital admission === On [[13 July]] [[1999]], Kouao took Victoria to Cameron's house, saying that Manning did not want Victoria, and asking them to keep her permanently. They refused but agreed to take her for the night. When they saw her injuries, they took her to [[Central Middlesex Hospital]], on [[14 July]] [[1999]]. The doctors alerted Brent [[police]] and social services, and she was placed under police protection, with a 72-hour protection order preventing her from leaving hospital. Kouao told the doctors that she had [[scabies]], and that the injuries were self-inflicted. Many doctors and nurses suspected that the injuries were non-accidental.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,568543,00.html Doctor 'suspected abuse']", ''The Guardian'', [[12 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> However, Ruby Schwartz, the [[consultant (medicine)|consultant]] [[pediatrics|paediatrician]] and named child protection doctor at the hospital, diagnosed scabies and decided that it was scratching that caused the injuries. She made the diagnosis without speaking to Victoria alone.<ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,574318,00.html Day that could have saved Victoria]", ''The Guardian'', [[13 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Schwartz later admitted that she made a mistake.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,573068,00.html Climbié doctor admits errors put girl at risk]", ''The Guardian'', [[12 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Another doctor, one of Schwartz' juniors, misleadingly wrote to social services saying there was no [[child welfare|child protection]] issue.<ref name="twelve"/> When Michelle Hine, a child protection officer at Brent council, received a report notifying her of Victoria's injuries, she planned to open an investigation into the case. However, the next day she heard of Schwartz' diagnosis and downgraded Victoria's level of care, trusting Schwartz' judgement. She later expressed regret over her actions.<ref>"[http://news.bbc.co.uk/1/hi/uk/1595517.stm Climbie social worker admits 'shortcoming']", BBC, [[12 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Butler, Patrick, "[http://society.guardian.co.uk/climbie/story/0,,568732,00.html 'I was wrong' admits Climbié social worker]", ''The Guardian'', [[12 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Schwartz said in the inquiry that she expected social services to follow up the case. Neil Garnham [[Queen's Counsel|QC]], [[counsel]] to the inquiry following Victoria's death, later said to her, "there is a terrible danger here – is there not, doctor – of social services on the one hand and you on the other each expecting the other to do the investigation, with the result that nobody does".<ref name="mind the gap">Batty, David, "[http://society.guardian.co.uk/children/story/0,,708254,00.html Mind the gap: coordinating care work]", ''The Guardian'', [[2 May]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> A [[police officer]] from Brent council, Rachel Dewar, decided to lift the police protection, allowing Victoria to return home, when told by a social worker that she had scabies. Under the [[Children Act 1989]], Dewar was obliged to see Victoria and tell her she was under police protection, but she did not do this.<ref>"[http://news.bbc.co.uk/1/hi/uk/1641218.stm PC 'handed Victoria back to abusers']", BBC, [[6 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> She also failed to see Kouao or Manning. At the time of the decision, Dewar was attending a seminar on child protection. Garnham later said, "we will need to ask why it was thought more important for her to attend a seminar to learn how to deal with child protection cases than deal with the real child protection case for which she was responsible at the time".<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/nov.htm#2NOV01 Witnesses to be Called in Week Beginning 5 November]", The Victoria Climbié Inquiry, [[2 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Kouao took Victoria home on [[15 July]] [[1999]]. "Some time in July, probably just before Victoria was admitted to the Central Middlesex Hospital", Kouao befriended a couple, Julien and Chantal Kimbidima. Victoria and Kouao visited their home several times over the following months. According to Chantal, Kouao would shout at Victoria all the time and never showed her affection.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 32: 3.53–3.55, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> === Second hospital admission === [[Image:North Middlesex Hospital.jpg|thumb|North Middlesex Hospital where Climbié was discharged after being treated for severe scalding]] On [[24 July]] [[1999]], Victoria was taken by Kouao to the [[emergency department|accident-and-emergency department]] at [[North Middlesex Hospital]] with severe [[burn (injury)|scalding]] to her head and other injuries. The hospital found no evidence of scabies. Consultant Mary Rossiter felt Victoria was being abused but still wrote 'able to discharge' on her notes.<ref name="chain of neglect">"[http://news.bbc.co.uk/1/hi/uk/2700427.stm Victoria Climbie: Chain of neglect]", BBC, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> According to Maureen Ann Meates, another doctor at the hospital, when Rossiter had written that note, she had noted that Victoria was exhibiting signs of neglect, [[emotional abuse]] and [[physical abuse]]. Later, in the inquiry, Rossiter said that by writing 'able to discharge', she did not mean she wanted Victoria to go home, merely that she was physically fit to leave. Garnham said, "quite how the subtlety of that distinction was to be ascertained from the notes is far from obvious".<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/nov.htm#9NOV01 Witnesses to be Called in Week Beginning 12 November]", The Victoria Climbié Inquiry, [[9 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Rossiter admitted to the inquiry that she had expected police and social services to follow up on the case.<ref name="people"/> For a brief period while she was in hospital, [[London Borough of Enfield|Enfield]] social services took up the case before passing it to Haringey. A social worker and police officer from Haringey council, Lisa Arthurworrey and Karen Jones, respectively, were assigned to her case, and were scheduled to make a home visit on [[4 August]] [[1999]]; however, the visit was cancelled once they heard about the scabies. Jones later said, "it might not be logical but I did not know anything about scabies". She said that she telephoned North Middlesex Hospital for information about the disease, but Garnham had evidence that the staff there dealt with no such inquiry.<ref>"[http://news.bbc.co.uk/1/hi/england/1664755.stm Climbie officer 'feared scabies']", BBC, [[19 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://news.bbc.co.uk/1/hi/uk/1039138.stm Girl died after scabies scared off police]", BBC, [[24 November]] [[2000]]. Retrieved on [[5 July]] [[2007]].</ref> Jones was told by a doctor that Victoria's injuries were consistent with belt buckle marks, although she claimed in the inquiry there was no evidence of child abuse.<ref name="people">Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,616539,00.html Key figures in the Climbié case]", ''The Guardian'', [[4 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> On [[5 August]] [[1999]], a Haringey social worker, Barry Almeida, took Victoria to a [[NSPCC|National Society for the Prevention of Cruelty to Children]] (NSPCC) centre in Tottenham, where she was assigned to Sylvia Henry. There was some confusion as to why the centre was being referred to for the case. Henry later contacted Almeida and was told, according to Henry, that Victoria had moved out of the borough, thereby closing the case. Almeida said he could not remember whether this conversation did take place. On the same day, Kouao met Arthurworrey and Jones at the Haringey social services department, and claimed that Victoria had poured boiling water over herself to stop the itching caused by the scabies and that she had used utensils to cause the other injuries. The social worker and police officer believed her, deciding that the injuries were probably accidental, and allowed Climbié to return home the following day, which she did.<ref name="BBC timeline">"[http://news.bbc.co.uk/1/hi/uk/2062590.stm Timeline: Victoria Climbie]", BBC, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,10939,557475,00.html Timeline for the Climbié case]", ''The Guardian'', [[24 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> === Post-hospital events === On [[7 August]] [[1999]], Kouao visited Ealing social services; they said it was a housing issue and that the case was closed.<ref name="twelve"/> Ealing social services would later be described as 'chaotic'.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,565697,00.html 'Chaotic' department lost track of Victoria]", ''The Guardian'', [[5 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> As a follow up measure, a staff member at the hospital contacted a [[health visitor]], but the health visitor said in the inquiry that she did not receive any contact.<ref name="twelve"/> On [[13 August]] [[1999]], Rossiter wrote to Petra Kitchman of Brent council, asking her to follow up on the Victoria case. Kitchman said in the inquiry that she contacted Arthurworrey, but Arthurworrey denied this. Later, on [[2 September]] [[1999]], Rossiter sent a second letter. Kitchman said she spoke to Arthurworrey about this, but Arthurworrey denied this again.<ref name="twelve"/> Arthurworrey made a visit to Victoria's home on [[16 August]] [[1999]] and another one when Manning began forcing Victoria to sleep in the bath. Arthurworrey said in the inquiry that she was under the impression that Victoria seemed happy, but Garnham criticised Arthurworrey for not detecting any of the abuse, although Manning had described this visit as a "put up job".<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 33: 3.61, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Arthurworrey and Victoria had met on four occasions, where they were together for a total of less than 30 minutes, barely speaking to each other.<ref>"[http://news.bbc.co.uk/1/hi/england/1677167.stm Social worker admits mistakes]", BBC, [[26 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="twelve"/> From then on, Kouao kept Victoria away from hospitals, turning instead to churches. Kouao said to the pastors that she was the mother and that [[demonic possession|demons were inside]] Victoria. The pastor at the Mission Ensemble Pour Christ, Pascal Orome, offered prayers for Victoria to cast out the devil, and thought that her injuries were due to demonic possession.<ref>"[http://news.bbc.co.uk/1/hi/uk/1586816.stm Cleric said Climbie was 'possessed']", BBC, [[8 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="people"/> On another occasion, Kouao took Victoria to a church run by the [[Universal Church of the Kingdom of God]], where the pastor, Alvaro Lima, suspected she was being abused, although he took no action. He said in the inquiry that Victoria told him that [[Satan]] had told her to burn herself. The pastor did not believe her, but he still believed that a person could be possessed.<ref>"[http://news.bbc.co.uk/1/hi/england/1695601.stm Pastor prayed for 'possessed' Victoria]", BBC, [[6 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> From October 1999 to January 2000, Manning forced Victoria to sleep in a [[bin liner]] in the bath in her own excrement. During a later police interview, Manning said this was because of her frequent [[bedwetting]]. At Haringey social services on [[1 November]] [[1999]], Kouao told social workers that Manning [[child sexual abuse|sexually assaulted]] Victoria, but withdrew the accusation the following day. In one of Arthurworrey's visits, during a conversation about housing, Arthurworrey said that the council only accommodated children believed to be at serious risk. Laming said in his report, "it may be no coincidence that within three days of this conversation, Kouao contacted Ms. Arthurworrey to make allegations which, if true, would have placed Victoria squarely within that category".<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 33: 3.62, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Jones sent a letter to Kouao, which was ignored, and no further action was taken.<ref name="BBC timeline"/> Manning later denied the allegation. Alan Hodges, the [[UK police ranks|police sergeant]] overseeing the investigation, claimed in the inquiry that the social workers were obstructing the police in dealing with child protection cases.<ref name="people"/> Between December 1999 and January 2000, Arthurworrey made three visits to the flat, but she received no answer. She speculated to her supervisor, Carole Baptiste, that they had returned to France. Despite no evidence, her supervisor wrote on Victoria's file that they had left the area. On [[18 February]] [[2000]] they wrote to Kouao saying that if they did not receive any contact from them, they would close the case. A week later, on [[25 February]] [[2000]], they closed the case – on the same day that Victoria died.<ref name="twelve"/> == Death and trial == [[Image:StMarysOldSection.jpg|left|thumb|St Mary's hospital, where Climbié died]] On [[24 February]] [[2000]], Victoria was taken [[unconsciousness|semi-conscious]] and suffering from [[hypothermia]], [[multiple organ dysfunction syndrome|multiple organ failure]] and [[malnutrition]], to the local Universal Church of the Kingdom of God church. The pastor there took her to the accident-and-emergency department at North Middlesex Hospital; she was then transferred to the [[intensive care medicine|intensive-care]] unit at [[St Mary's Hospital, London|St Mary's Hospital]]. The ambulance driver who drove her to St Mary's described how although Kouao had kept saying, "my baby, my baby", her concern seemed "not quite enough", and that Manning seemed "almost as if he was not there".<ref>"[http://news.bbc.co.uk/1/hi/uk/1569144.stm Driver found Victoria lifeless]", BBC, [[28 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Victoria died the following day at 3:15pm local time – on the same day the Universal Church of the Kingdom of God church was planning to hold a service of deliverance for her to cast out the devil.<ref name="life of horror"/> The [[Home Office]] [[pathology|pathologist]] who examined her body noted 128 separate injuries and scars on her body, and described it as "the worst case of child abuse I've encountered".<ref name="BBC timeline"/> She had been burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires; and was known to four local authorities (four social services departments and three housing departments), two child protection police teams, two hospitals, an NSPCC centre, and a few local churches. She was buried in [[Grand-Bassam]] near her home town. Kouao was arrested on the day that Victoria died, and Manning the following day. She told police, "It is terrible, I have just lost my child".<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/vicstory.htm ''Report of an Inquiry''], p. 37: 3.85, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> On [[20 November]] [[2000]] at the [[Old Bailey]], the [[trial (law)|trial]] into her death opened, with Kouao and Manning being charged with [[child abuse|child cruelty]] and murder. Kouao denied all charges, and Manning pleaded guilty to charges of cruelty and [[manslaughter]].<ref name="BBC timeline"/> The judge described the teams in Victoria's case as "blindingly incompetent".<ref>"[http://news.bbc.co.uk/1/hi/uk/1113740.stm Inquiry into Climbie officials]", BBC, [[12 January]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> During police interviews, both claimed that Victoria was possessed. In his diary, Manning described Victoria as [[Satan]],<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/jan.htm Witnesses to be Called in Week Beginning 28 January]", The Victoria Climbié Inquiry, [[25 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> and said that no matter how hard he hit her, she did not cry or show signs that she was hurt. On [[12 January]] [[2001]], both were found guilty and sentenced to [[life imprisonment]].<ref>"[http://news.bbc.co.uk/1/hi/uk/1106709.stm Victoria carers guilty of murder]", BBC, [[20 February]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> The judge said to them, "what Anna endured was truly unimaginable. She died at both your hands, a lonely drawn out death". Kouao went to [[Durham (HM Prison)|Durham prison]] and Manning went to [[Wakefield (HM Prison)|Wakefield prison]]. == Inquiry == On [[20 April]] [[2000]], the then–[[Secretary of State for Health|health secretary]], [[Alan Milburn]], and the then–[[Home Secretary|home secretary]], [[Jack Straw]], called for an inquiry into her death. The inquiry, announced in April 2001 and launched on [[31 May]] [[2001]],<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/may.htm#31may2001 Victoria (Anna) Climbié inquiry is launched]", The Victoria Climbié Inquiry, [[31 May]] [[2007]]. Retrieved on [[27 June]] [[2007]].</ref> was chaired by [[Herbert Laming, Baron Laming|William Laming]], former chief inspector of the social services inspectorate (SSI). Laming was given the choice of staging a [[public inquiry]] or a private inquiry; he chose a public inquiry.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/inquiry.htm ''Report of an Inquiry''], p.16: 2.11, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> This was the first public inquiry to be set up by two [[Secretary of State (United Kingdom)|secretaries of state]].<ref name="short shrift">Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,884377,00.html Short shrift for those who dared to obstruct the inquiry's progress]", ''The Guardian'', [[29 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry (actually three inquiries together called ''The Victoria Climbié Inquiry'') has a [[statute|statutory base]] of three pieces of [[legislation]]: section 81 of the [[Children Act 1989]], section 84 of the National Health Service Act 1977, and section 49 of the Police Act 1996, drawing together the involvement of social services, the [[National Health Service]], and the police; and becoming the first 'tripartite' inquiry into child protection. The Counsel to the Inquiry was Neil Garnham [[Queen's Counsel|QC]]. The inquiry offices were based in [[Hannibal House]], [[Elephant and Castle]], London. The inquiry cost £3.8m, making it the most expensive child protection investigation in British history.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,557457,00.html Climbié inquiry: the issue explained]", ''The Guardian'', [[5 August]] [[2005]]. Retrieved on [[5 July]] [[2007]].</ref> A website, www.victoria-climbie-inquiry.org.uk, was created, where all the evidence and documents were made available freely. === Laming controversy === Laming's appointment was controversial as he had been director of [[Hertfordshire|Hertfordshire county council]]'s social services department in 1990, a department which was strongly criticised for its handling of a child abuse case, and which had the [[Local Government Ombudsman|local government ombudsman]] making a finding of '[[maladministration]] with injustice' against them in 1995. The father of the child in the case said of Laming's appointment, "I don't see how he has the qualifications or experience to be able to lead an investigation into another borough which has been failing to protect a child in exactly the same manner that his own authority failed to protect a child in 1990".<ref>Verkaik, Robert, "[http://findarticles.com/p/articles/mi_qn4158/is_20010120/ai_n9660058 Head of Anna Climbie inquiry ran department that failed to protect]", ''The Independent'' (via findarticles.com), [[20 January]] [[2001]]. Retrieved on [[3 July]] [[2007]].</ref> [[Liberal Democrats|Liberal Democrat]] spokesman [[Paul Burstow]] said, "the findings of the ombudsman in the Hertfordshire case must give rise to questions about Lord Laming's appointment to head this inquiry"; and [[Conservative Party (UK)|Conservative Party]] spokesman [[Liam Fox]] said, "I think the government maybe should have thought twice about this and maybe, even yet, they will think again". The [[Department of Health (United Kingdom)|Department for Health]], however, said that they were "fully confident that he is the right person to conduct the inquiry".<ref>"[http://society.guardian.co.uk/socialcare/news/0,,424944,00.html Climbié inquiry chief under fire]", ''The Guardian'', [[19 January]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> === Obstruction of evidence === Several documents were submitted late or in suspicious circumstances. A report by the SSI was submitted late because the SSI presumed the document was not relevant to the inquiry. The report was produced in April 2001 but was not handed over to the inquiry until 2002. An earlier report by the Joint Review about Haringey social services, which was heavily relied upon during the inquiry, said that service users were "generally well served"; the SSI report said that the former report presented "an overly positive picture of Haringey's social services, particularly children's services".<ref>"[http://news.bbc.co.uk/1/hi/england/2038309.stm New Climbie hearing over 'missing report']", BBC, [[11 June]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Further documents were received late, when Haringey council handed in 71 case documents five months after the hearings began.<ref>"[http://news.bbc.co.uk/1/hi/england/1801342.stm Climbie parents' anger at 'missing files']", BBC, [[4 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Laming said, "it shows a blatant and flagrant disregard to the work of this inquiry".<ref>"[http://news.bbc.co.uk/1/hi/england/1795721.stm Council blunder halts Climbie inquiry]", BBC, [[1 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> The people involved were threatened with disciplinary action. This was not the first time that Haringey council did not produce documents on time, which led Laming to say to its chief executive, "it is a long sad and sorry saga of missed dates and missed timetables".<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,617133,00.html Council chief under fire for 'sorry saga' of delays]", ''The Guardian'', [[11 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="inquiry injustice">Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,618183,00.html Fears of Climbié inquiry 'injustice']", ''The Guardian'', [[13 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Garnham warned that Haringey senior managers, who had access to the documents, would enjoy an unfair advantage in the inquiry, but Laming said he was "determined that Haringey is not given any advantage".<ref name="inquiry injustice"/> The inquiry found contradictory information in the NSPCC's files. One file said that Victoria's case was "accepted for ongoing service", whilst another computer record, made after Victoria's death, said that "no further action" was to be taken, suggesting the possibility that records may have been changed. Documents given to the inquiry may also have been altered: the NSPCC provided photocopies of an original document, which had alterations in them, saying that the originals were lost; however, the originals were later produced with pressure from the inquiry.<ref>"[http://news.bbc.co.uk/1/hi/england/1781399.stm NSPCC 'delayed action' over Climbie]", BBC, [[25 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="twelve"/><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,623718,00.html NSPCC told to explain discrepancies in evidence]", ''The Guardian'', [[21 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The NSPCC held an internal investigation but found no evidence of deception.<ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,639767,00.html NSPCC denies Climbié deceit]", ''The Guardian'', [[26 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry was split into two phases: phase one and phase two. Phase one investigated the involvement of people and agencies in Victoria's death, in the form of [[hearing (law)|hearings]]. Two hundred and seventy [[witness]]es were involved. The phase one hearings began on [[26 September]] [[2001]] and finished on [[31 July]] [[2002]]; it was originally supposed to end on [[4 February]] [[2002]] but late documents caused delays. Phase two of the inquiry, taking place between [[15 March]] [[2002]] and [[26 April]] [[2002]], took the form of five seminars, which looked at the child protection system in general. It was chaired by Garnham and brought together experts in all aspects of child protection.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/5seminars_purpose.htm ''Report of an Inquiry], pp. 349–370: 17.1–17.121, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,637569,00.html Guide: the Climbié inquiry phase two]", ''The Guardian'', [[27 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> === Hearings === The inquiry heard that many of the councils were under-staffed, under-funded, and poorly managed. The chief executive of Brent council said its social services department was "seriously defective".<ref>Butler, Patrick, "[http://society.guardian.co.uk/climbie/story/0,,577268,00.html Climbiés 'badly served' by Brent social services]", ''The Guardian'', [[19 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry was told that many cases at Brent social services were closed inappropriately before inspection by the social services inspectorate,<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,566475,00.html Climbié council closed cases inappropriately]", ''The Guardian'', [[9 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> that children were being placed unaccompanied in bed-and-breakfast accommodation, and that children in need were turned away.<ref>"[http://news.bbc.co.uk/1/hi/uk/1593825.stm Climbie hearing sparks B&B inquiry]", BBC, [[11 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry heard how Edward Armstrong had previously been ordered not to work with children over his handling of a case in 1993.<ref>Butler, Patrick, "[http://society.guardian.co.uk/climbie/story/0,,575800,00.html Climbié social worker 'barred from working with children']", ''The Guardian'', [[17 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Haringey and Brent council diverted £18.7m and over £26m, respectively, in the two years 1997/98 and 1998/99, from its social services department into services such as education, for the purpose of gaining votes; both underspent their budgets for children's services, totalling £28m, by more than £10m in 1998–99, causing a deteriorating of child protection services.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,559984,00.html Councils underspent for children's services, Climbié inquiry told]", ''The Guardian'', [[28 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://society.guardian.co.uk/climbie/story/0,,620657,00.html 'Social services cash went to education']", ''The Guardian'', [[18 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/dec.htm Witnesses to be Called in Week Beginning 17 December]", The Victoria Climbié Inquiry, [[14 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Butler, Patrick, "[http://society.guardian.co.uk/climbie/story/0,,576651,00.html Overstretched child care service 'unravelled']", ''The Guardian'', [[18 October]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry heard how Haringey council failed to assign social workers to 109 children in May 1999, a short period before they took on Victoria's case.<ref>"[http://society.guardian.co.uk/climbie/story/0,,636902,00.html Climbié council left 109 children unprotected]", ''The Guardian'', [[18 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Again in January 2002, Haringey council failed to assign social workers to about 50 children.<ref>"[http://society.guardian.co.uk/climbie/story/0,,641929,00.html Vulnerable children left unprotected]", ''The Guardian'', [[30 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Haringey council wrote a letter to Laming claiming that social workers who gave evidence were being questioned more harshly than other witnesses. Laming condemned the letter, saying "I will not tolerate any covert attempt to influence the way in which the inquiry is conducted."<ref>"[http://society.guardian.co.uk/climbie/story/0,,592243,00.html Haringey blasted for 'attempt to influence' Climbié inquiry]", ''The Guardian'', [[12 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Mary Richardson, the director of social services at Haringey from 1 April 1998 until 31 March 2000, had been responsible for a restructuring of the department which, according to the union [[UNISON|Unison]], had "virtually paralysed" the child protection service. She received contact from twelve senior practitioners and team managers criticising the proposals as "potentially dangerous and detrimental to the people to whom we offer a service". Richardson provided no substantive response to the memorandum.<ref>[http://www.victoria-climbie-inquiry.org.uk/News_Update/dec.htm#10dec01 Witnesses to be Called in Week Beginning 10 December]", The Victoria Climbié Inquiry, [[7 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> She did, however, say in the inquiry that the blame lay on "part of all of the line management responsibility".<ref>[http://www.victoria-climbie-inquiry.org.uk/Evidence/Archive/Dec01/191201latestp1.htm Archived Transcript for 19 December 2001: Page 19], The Victoria Climbié Inquiry, [[19 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> In April 2000, she became head of [[London Borough of Hackney|Hackney]]'s social services department, with a salary of £100,000.<ref>Payne, Stewart, "[http://www.adoption-net.co.uk/news/2001/jan/010122topjob.htm Top job for Anna social work chief]", adoption-net.co.uk, [[22 January]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Gurbux Singh, the former chief executive of Haringey council (before becoming the chairman of the [[Commission for Racial Equality]]), said that there was nothing he could have done to prevent Victoria's death.<ref>"[http://society.guardian.co.uk/climbie/story/0,,620700,00.html Ex-council chief: 'I could not have prevented Victoria's death']", ''The Guardian'', [[18 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://society.guardian.co.uk/climbie/comment/0,,621248,00.html Singh washes his hands of blame]", ''The Guardian'', [[19 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Garnham contrasted this with Rossiter's willingness to accept responsibility, saying, "that willingness to acknowledge error is at least at the root, is it not, of progress?"<ref>Eaton, Lynn, "[http://society.guardian.co.uk/climbie/story/0,,669644,00.html The cost of culpability]", ''The Guardian'', [[18 March]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Kouao herself was called to the inquiry, becoming the first convicted murderer to appear in person in a public inquiry.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,618986,00.html Climbié murderer to give evidence in person]", ''The Guardian'', [[14 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> She initially refused to answer questions, and when she did, protested her innocence, first in French, then, raising her voice in anger, in English.<ref>"[http://news.bbc.co.uk/1/hi/england/1748718.stm Climbie killer disrupts inquiry]", BBC, [[8 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,629842,00.html 'They did not love their little girl like me']", ''The Guardian'', [[9 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Giving evidence by video link from prison, Manning apologised for his actions and said that it was not the fault of the various agencies that Victoria died.<ref>"[http://news.bbc.co.uk/1/hi/england/1792336.stm Climbie killer says sorry]", BBC, [[30 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Allison, Rebecca, "[http://society.guardian.co.uk/climbie/story/0,,642050,00.html Climbié killer apologises for part in 'sickening' death]", ''The Guardian'', [[31 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,641960,00.html Manning: social services were not to blame]", ''The Guardian'', [[30 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Broadcasters applied for access to this video, but Laming refused the application.<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/inquiry.htm ''Report of an Inquiry''], p.20: 2.44, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Victoria's parents gave evidence and were present at most of the hearings, becoming distressed when hearing of Victoria's plight and seeing pictures of her injuries. They blamed Haringey council and its chief executive for Victoria's death. Arthurworrey, a junior worker with only nineteen months of child protection experience when she took on Victoria's case,<ref name="inexperienced">Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,561336,00.html 'Inexperienced' social worker left to make complex decisions]", ''The Guardian'', [[28 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> was found to have made mistakes in the case.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,1320264,00.html Climbié investigator widens focus of blame]", ''The Guardian'', [[5 October]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref> She accused her employer of "making her a [[scapegoat]]", and criticised her superiors and department for not guiding her properly.<ref>"[http://society.guardian.co.uk/climbie/story/0,,1319450,00.html Climbié social worker 'made a scapegoat']", ''The Guardian'', [[4 October]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry heard that Arthurworrey was overworked, taking on more cases than guidelines allow.<ref name="inexperienced"/> Carole Baptiste, Arthurworrey's first supervisor, initially refused to attend the hearings, but subsequently gave vague responses to the inquiry,<ref name="amnesia">Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,634028,00.html Amnesia strikes Climbié social work manager]", ''The Guardian'', [[15 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> and said that she had been suffering from [[mental illness]] at the time.<ref>"[http://news.bbc.co.uk/1/hi/england/1764321.stm Climbie official had 'psychotic illness']", BBC, [[16 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,634687,00.html Climbié case social worker 'had mental illness']", ''The Guardian'', [[17 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Baptiste's own child was taken into care a few months before Victoria's death.<ref name="amnesia"/> Arthurworrey said that, in their meetings, Baptiste spent most of the time discussing "her experiences as a black woman and her relationship with God", rather than child protection cases, and that she was frequently absent.<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/jan.htm Witnesses to be Called in Week Beginning 14 January]", The Victoria Climbié Inquiry, [[11 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Baptiste admitted she had not read Victoria's file properly.<ref name="chain of neglect"/> She was removed in November 1999 when she was found to be professionally unfit for her job, and replaced by Angella Mairs, who became Arthurworrey's new supervisor. Mairs was accused by Arthurworrey of not maintaining childcare standards<ref name="people"/> and of removing an important document – which recommended that Victoria's case be closed – from Victoria's file on [[28 February]] [[2000]], the day the news of the death was known; but she denied this. Mairs said that she had not read Victoria's file.<ref>"[http://news.bbc.co.uk/1/hi/england/1697904.stm Manager denies destroying Climbie paper]", BBC, [[7 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The inquiry heard how the number of child protection police officers in the [[Metropolitan Police Service]] were reduced to increase the number of murder investigation officers, due to the recent [[Stephen Lawrence]] case.<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/feb.htm Witnesses to be Called in Week Beginning February 4]", The Victoria Climbié Inquiry, [[1 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> A [[UK police ranks|detective inspector]] supervising six child protection teams in London at the time of Victoria's death wrote a report criticising their competence. His former boss, however, claimed he had been lying when he said he only held "purely administrative" responsibility for the teams.<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,632727,00.html Climbié detective accused of lying]", ''The Guardian'', [[14 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> The detective inspector was taken to hospital when a woman poured ink over his head while testifying.<ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,631056,00.html Ink attack halts Climbié inquiry]", ''The Guardian'', [[11 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> The new chief executive of Haringey council, David Warwick,<ref>"[http://news.bbc.co.uk/1/hi/england/1704002.stm Council boss apologises to Climbie inquiry]", BBC, [[11 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Baptiste,<ref>"[http://news.bbc.co.uk/1/hi/england/1761502.stm Climbie parents reject apology]", BBC, [[15 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> the Metropolitan Police,<ref>"[http://news.bbc.co.uk/1/hi/england/1827406.stm Officers in Climbie case 'scapegoats']", BBC, [[18 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> and the NSPCC<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,652374,00.html NSPCC 'sorry' for Climbié failings]", ''The Guardian'', [[18 February]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> apologised for their failings in the case. === Racial considerations === In his opening speech on [[26 September]] [[2001]], Garnham said that [[Race (classification of human beings)|race]] may have played a part in the case, due to the fact that a [[black people|black child]] was murdered by her black carers, and the social worker and police officer most closely involved in the case were black. He said that the fear of being accused of [[racism]] may have led to the inaction.<ref>"[http://news.bbc.co.uk/1/hi/uk/1565254.stm Sombre mood at Climbie inquiry]", BBC, [[26 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,558923,00.html Catalogue of errors in abuse case]", ''The Guardian'', [[27 September]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> In the hearings, Arthurworrey, who is [[African–Caribbean]], admitted that her assumptions about African–Caribbean families influenced her judgement, and that she had assumed Victoria's timidness in the presence of Kouao and Manning stemmed not from fear, but from the African–Caribbean culture of respect towards one's parents.<ref>"[http://news.bbc.co.uk/1/hi/england/1672265.stm Social worker 'made cultural judgement']", BBC, [[23 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> Ratna Dutt, director of the Race Equality Unit (now the [[Race Equality Foundation]]), a charity that provides race-awareness training to social workers, later said, "the implicit message is that it's acceptable for [[ethnic minorities]] to receive poor services under the guise of superficial [[cultural sensitivity]]. This is absolutely shameful, as it allows people to argue that good practice is compromised by [[anti-racism]]"; and, contrasting the outcomes of the white and black staff members involved, "for a large number of black frontline staff if the finger of blame is pointed at them they don't end up in jobs in other local authorities. That's how [[institutional racism]] operates".<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,672479,00.html Political correctness or poor practice?]", ''The Guardian'', [[25 March]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> [[Jacqui Smith]], [[Home Secretary]] from 2007, said: "I have not seen widespread evidence that social workers are not taking action", and, "there are no cultures that condone child abuse. We are absolutely clear that social workers and social work departments have a responsibility to consider whether children are subjected to harm, and if they think they are, to take action".<ref name="political">"[http://society.guardian.co.uk/climbie/story/0,,623077,00.html Politicial <nowiki>[</nowiki>''sic''<nowiki>]</nowiki> correctness 'puts children at risk']", ''The Guardian'', [[20 December]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> One chapter of the report following the inquiry looked at this issue.<ref>Laming, William, "[http://www.victoria-climbie-inquiry.org.uk/finreport/4working.htm ''Report of an Inquiry''], pp.345–347: 16.1–16.3, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> == Aftermath == === Laming report=== When both phases of the inquiry were completed, Laming began writing the final report. The Laming report, published on [[28 January]] [[2003]],<ref>"[http://www.victoria-climbie-inquiry.org.uk/News_Update/jan03.htm#2jan03 Victoria Climbié Report Calls for Radical Change in the Management of Public Services for Children and Families]", [[28 January]] [[2003]]; Laming, William, {{PDFlink|''[http://www.victoria-climbie-inquiry.org.uk/finreport/report.pdf Report of an Inquiry]''|1.74&nbsp;[[Mebibyte|MiB]]<!-- application/pdf, 1831701 bytes -->}}, [[28 January]] [[2003]]. The Victoria Climbié Inquiry. Retrieved on [[5 July]] [[2007]].</ref> found that the agencies involved in her care had failed to protect her, and that on at least twelve occasions, workers involved in her case could have prevented her death, particularly condemning the senior managers involved.<ref>Gillan, Andrew, "[http://society.guardian.co.uk/climbie/story/0,,884390,00.html 'Her suffering and death marked a gross failure of the system and were inexcusable']", ''The Guardian'', [[29 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,883979,00.html Scathing criticism for managers' neglect]", ''The Guardian'', [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> On the day of the launch of the report, Victoria's mother sang Victoria's favourite song as a tribute.<ref>"[http://society.guardian.co.uk/climbie/story/0,,884129,00.html Mother pays emotional tribute]", ''The Guardian'', [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> The 400-page report, which made 108 recommendations in child protection reform,<ref>Laming, William, [http://www.victoria-climbie-inquiry.org.uk/finreport/6recommend.htm ''Report of an Inquiry''], pp. 371–384, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> led to the formation of the [[Every Child Matters]] programme, a framework to improve the lives of children; the introduction of the Children Act 2004, an [[Act of Parliament]] that provides the legislative base for many of the reforms; the creation of [[ContactPoint]], a database that will hold information on all children in [[England and Wales]]; and the creation of the post of [[Children's Commissioner for England|children's commissioner]], who heads the Office of the Children's Commissioner, a national agency serving children and families. Regional and local committees for children and families are to be set up, with members from all groups involved in child protection.<ref>Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,884441,00.html Full-time emergency service required, not bureaucracy]", ''The Guardian'', [[29 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Previously each local authority managed their own child protection register, a list of children believed to be at risk, and no national register existed;<ref>"[http://www.kirklees.gov.uk/community/health-care/childrenandfamilies/protectionregister.shtml Child Protection Register]", Kirklees Council, June 2006. Retrieved on [[5 July]] [[2007]].</ref> this, combined with local authorities' tendency to suppress information about child abuse cases, led to the implementation of the child database.<ref>Gillan, Audrey; Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,883836,00.html Lack of national register blamed for failure to protect children at risk]", ''The Guardian'', [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> The child protection register will be abolished and replaced by the database in 2008. Two organisations to improve the care of children, the [[General Social Care Council]] and the Social Care Institute for Excellence, had already been set up by the time the report was published. === Criticism of agencies=== Following Victoria's death, the agencies in the case, as well as the child services system in general, were criticised. Milburn said, "this was not a failing on the part of one service, it was a failing on the part of every service".<ref>"[http://society.guardian.co.uk/climbie/story/0,,884088,00.html Full text: Alan Milburn's statement on the Laming report]", ''The Guardian'', [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Fox said Victoria's case amounted to "a shocking tale of individual professional failure and systemic incompetence".<ref name="trusts">"[http://news.bbc.co.uk/1/hi/health/2702425.stm Trusts to take over child care]", BBC, [[28 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Burstow said, "there is a terrible sense of [[déjà vu]] in the Laming Report. The same weaknesses have led to the same mistakes, with the same missed opportunities to save a tortured child's life".<ref name="trusts"/> [[Labour Party (UK)|Labour Party]] [[Member of Parliament|member of parliament]] [[Karen Buck]] said, "the Bayswater families unit told me that there must be hundreds of other Climbié cases waiting to happen", and "the Victoria Climbié inquiry highlighted how easy it is for vulnerable families to fall through the net, especially if they do not have English as a first language and are highly mobile".<ref>Weaver, Matt, "[http://society.guardian.co.uk/climbie/story/0,,595927,00.html 'Hundreds of Climbié cases waiting to happen']", ''The Guardian'', [[16 November]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> The 1999 Department of Health document, Working Together to Safeguard Children (now superseded),<ref>[http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=24312&Rendition=Web Working Together to Safeguard Children], Department of Health, 1999. Retrieved on [[5 July]] [[2007]].</ref> set out child protection guidance to doctors, nurses, and midwives. The [[Royal College of Nursing]], however, said that there was evidence that many nurses did not receive proper training in these areas.<ref>Butler, Patrick, "[http://society.guardian.co.uk/climbie/comment/0,,668205,00.html Inquiry lays bare gaps in joint working]", ''The Guardian'', [[18 March]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Denise Platt, chief inspector of the social services inspectorate (SSI), said doctors, police officers and teachers often thought their only responsibility was to help social services, forgetting that they had a distinct role to play. Mike Leadbetter, president of the Association of Directors of Social Services, said that many health professionals were "not engaged in child protection".<ref name="mind the gap"/> After the inquiry, there was a feeling that senior managers had managed to escape responsibility and that only junior staff members were punished.<ref>Eaton, Lynn, "[http://society.guardian.co.uk/climbie/story/0,,669644,00.html The cost of culpability]", ''The Guardian'', [[18 March]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref><ref name="short shrift"/> Burstow said, "the majority of children who die from abuse or neglect in this country know the perpetrator; it is within the family and by 'friends' that most abuse occurs. As a society we are still in denial about that hard truth".<ref name="cycle of abuse">Katwala, Sunder; Ciglerova, Jana, "[http://society.guardian.co.uk/climbie/story/0,,883104,00.html How can the cycle of abuse be broken?]", ''The Observer'', [[26 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> === Criticism of the report=== The Laming report was criticised by Caroline Abrahams and Deborah Lightfoot of [[NCH]] as too narrow, focusing too much on the particular case of Victoria Climbié and not on general child protection.<ref>Caroline Abrahams and Deborah Lightfoot writing in ''The Guardian'', "[http://society.guardian.co.uk/climbie/comment/0,,886382,00.html The bigger picture]", ''The Guardian'', [[31 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> According to Harry Ferguson, a professor of social work at the [[University of the West of England]], "Laming's report focuses too heavily on the implementation of new structures and fails to understand the keen intuition that child protection work demands".<ref>Harry Ferguson writing in ''The Guardian'', "[http://society.guardian.co.uk/climbie/comment/0,,885515,00.html The sixth sense]", ''The Guardian'', [[30 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> He criticised the approach to child protection of focusing too much on the worst cases and trying too much prevent them, rather than having an approach that also celebrates success; and said that focusing too much on any individual case and basing reforms on that was "deeply problematic".<ref>Harry Ferguson writing in ''The Guardian'', "[http://society.guardian.co.uk/climbie/comment/0,,633964,00.html Blame culture in child protection]", ''The Guardian'', [[16 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Laming responded to criticism by the Association of Directors of Social Services that his recommendations would require much more funding by saying that these arguments lacked "intellectual rigour", and he dismissed claims that his reforms would be [[red tape|too bureaucratic]].<ref>Batty, David, "[http://society.guardian.co.uk/climbie/story/0,,922920,00.html Climbié inquiry head attacks social workers' 'kneejerk' response]", ''The Guardian'', [[27 March]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> ''[[The Guardian]]'' said that the report does not address the issues of frontline staff.<ref>Batty, David, "[http://www.guardian.co.uk/child/story/0,,884492,00.html Opportunity knocked]", ''The Guardian'', [[29 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Deryk Mead of NCH said, "I do believe that inquiry reports have made a positive difference to the child protection system, and I have every confidence that Lord Laming's report will do so too".<ref name="cycle of abuse"/> === Other=== ''The Guardian'' discussed the media attention surrounding the case, noticing how [[sensationalism|sensational]] events received widespread coverage, but important but less exciting events received less. It states that only ''The Guardian'' and ''[[The Independent]]'' of the national newspapers gave significant coverage to the evidence in the hearings. A possible explanation is given as, "much of the evidence has been concerned with social services, which many other papers view as a [[political correctness|politically correct]] waste of money for the undeserving".<ref>Batty, David, "[http://society.guardian.co.uk/climbie/comment/0,,635712,00.html Sensationalism will obscure the point of the Climbié inquiry]", ''The Guardian'', [[21 January]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> In August 2002, Baptiste was fined £500 after being found guilty of deliberately failing to attend the inquiry. Victoria's parents, speaking through a family friend, said, "we, the family, expected her to be dealt with more severely". This was the first time a person had been prosecuted for not attending a public enquiry.<ref>"[http://news.bbc.co.uk/1/hi/england/2219317.stm Climbie social worker guilty]", BBC, [[27 August]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> In September 2002, Arthurworrey and Mairs were sacked following disciplinary procedures.<ref>"[http://news.bbc.co.uk/1/hi/england/2449743.stm Climbie social workers sacked]", BBC, [[12 November]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> The then–[[Secretary of State for Education and Skills|education secretary]], [[Charles Clarke]], also added them to the Protection of Children Act 1999 List, banning them from working with children. In October 2004, Arthurworrey appealed against her dismissal, saying that she was duped by Kouao and Manning, misled by medical reports, badly advised by her managers, and that she was a scapegoat for other people's failures, but the appeal was rejected.<ref>"[http://news.bbc.co.uk/1/hi/england/london/3712360.stm Climbie social worker fights sack]", BBC, [[4 October]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref><ref>"[http://news.bbc.co.uk/1/hi/england/london/3726958.stm Sacked Climbie worker loses case]", BBC, [[8 October]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref> In 2005, she appealed the ban preventing her from working with children and won.<ref>"[http://news.bbc.co.uk/1/hi/uk/4075574.stm Climbie worker's ban overturned]", BBC, [[9 June]] [[2005]]. Retrieved on [[5 July]] [[2007]].</ref> In 2004, Mairs appealed her ban preventing her from working from children and won; this decision was challenged in the [[High Court of Justice|High Court]] but she prevailed.<ref>"[http://news.bbc.co.uk/1/hi/england/london/4578631.stm Climbie worker wins court battle]", BBC, [[25 May]] [[2005]]. Retrieved on [[5 July]] [[2007]].</ref> In 2004, six police officers involved in the case faced misconduct charges.<ref>"[http://news.bbc.co.uk/1/hi/england/london/3900211.stm Climbie police to face tribunal]", BBC, [[16 July]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref> All six kept their job, and some received reprimands and cautions.<ref>"[http://news.bbc.co.uk/1/hi/england/london/4563875.stm Climbie officers keep their jobs]", BBC, [[19 May]] [[2005]]. Retrieved on [[5 July]] [[2007]].</ref> In 2004, the [[General Medical Council]] dropped misconduct charges against Dr. Schwartz.<ref>"[http://news.bbc.co.uk/1/hi/england/london/3637986.stm GMC drops Climbie doctor charges]", BBC, [[8 September]] [[2004]]. Retrieved on [[5 July]] [[2007]].</ref> Haringey council held a debate in the council chambers to discuss the Laming report. The parents of Victoria Climbie were invited to speak at the council by Councillor Ron Aitken<ref>"[http://www.lynnefeatherstone.org/news631.htm Website of Lynne Featherstone, Member of Parliament for Hornsey and Wood Green "Invite to parents of Climbie to attend council meeting", dated 21 February 2003, accessed 30 May 2008.]</ref>, but the Council leader George Meehan denied then permission. Only pressure from the opposition and local press got the decision reversed. As George Meehan only reversed his decision just before the meeting, a driver was rushed to Acton to escort Francis and Berthe Climbie and Mor Dioum, their interpreter, to the council. At the meeting, Victoria Climbies parents attacked the council, through their interpreter, for its handling of the case, especially in its dealing with the Laming Inquiry. (Mor Dioum later went on to be the Director of the Victoria Climbié Foundation) The government placed Haringey social services department under [[special measures]], requiring close supervision by the social services inspectorate. Allegations emerged that in 2004 and 2005, senior managers at Haringey council ignored child abuse cases and "became hostile" against a social worker who sought to expose the abuse.<ref>Verkaik, Robert, "[http://news.independent.co.uk/uk/legal/article2287044.ece Climbie council 'is still failing abused children']", ''The Independent'', [[20 February]] [[2007]]. Retrieved on [[5 July]] [[2007]].</ref> Victoria's parents created the Victoria Climbié Foundation UK,<ref>[http://www.victoria-climbie.org.uk/index.php Victoria Climbié Foundation UK]; [http://www.victoria-climbie.org.uk/index.php?option=com_content&task=blogsection&id=6&Itemid=34 Victoria Climbié Foundation UK - About us]. Retrieved on [[5 July]] [[2007]].</ref> a charity that seeks to improve child protection policies, and the Victoria Climbié Charitable Trust,<ref>[http://www.victoriaclimbietrust.org.uk/ Victoria Climbié Charitable Trust]. Retrieved on [[5 July]] [[2007]].</ref> an organisation to build a school in the [[Côte d'Ivoire|Ivory Coast]]. Funding for the school has been raised, construction has started and will be completed by November 2007.<ref>[http://www.charitygiving.co.uk/minisites/default.asp?subname=victoriaclimbiecharitabletrust Charity Giving - Mini Sites - Victoria Climbié Charitable Trust], charitygiving.co.uk. Retrieved on [[5 July]] [[2007]].</ref> Victoria's parents are also involved in championing many child protection reforms. A playwright, Lance Nielsen, wrote a play based on the events, staged at the [[Hackney Empire]] throughout 2002.<ref>"[http://society.guardian.co.uk/climbie/story/0,,715956,00.html Climbié playwright attacks 'cash over care' culture]", ''The Guardian'', [[15 May]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> After Victoria's death, commentators discussed the history of child protection and the various abuse and death cases,<ref>"[http://society.guardian.co.uk/climbie/story/0,,885395,00.html Q&A: Victoria Climbié inquiry]", ''The Guardian'', [[30 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref><ref>Brindle, David; Carvel, John, "[http://society.guardian.co.uk/climbie/story/0,,530844,00.html Anna: the fatal failings]", ''The Guardian'', [[9 May]] [[2001]]. Retrieved on [[5 July]] [[2007]].</ref> noting that there have been 70 public inquiries into child abuse since 1945, and comparing Victoria's case with that of many others, especially that of Maria Colwell in 1973. They pointed to the many children abused and killed by their guardians over the years and how the agencies involved in their care let them down. They noted similarly that their deaths also led to inquiries and reform policies – reforms that have not saved the many children killed following them. They pointed out that, "an average of 78 children are killed by parents or minders every year; a figure unaltered in the 30 years since [[Maria Colwell]]'s death provoked the first criticism of 'communications failure'".<ref>"[http://society.guardian.co.uk/climbie/comment/0,,883105,00.html Put children first]", ''The Observer'', [[26 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> They expressed cynicism towards the possibility that these reforms would be different.<ref>"[http://news.bbc.co.uk/1/hi/england/2580493.stm Climbie: Legacy of an inquiry]", BBC, [[17 December]] [[2002]]. Retrieved on [[5 July]] [[2007]].</ref> Dr. Chris Harvey, director of operations at [[Barnardo's]], for example, said, "Victoria's tragic case is the latest in a sad roll-call of child deaths, each leading to fresh inquiries and a new but recurring set of recommendations".<ref>Chris Hanvey writing in ''The Observer'', "[http://society.guardian.co.uk/climbie/comment/0,,882568,00.html The lessons we never learn]", ''The Observer'', [[26 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> Ian Willmore, former deputy leader of Haringey council, said, "the "script" for this kind of Inquiry is now almost traditional. The Minister goes on TV to insist that: "this must never happen again". Responsibility is pinned on a few expendable front-line staff, all conveniently sacked in advance. Criticisms are made about poor communication, with earnest recommendations about better co-ordination and possible restructuring. Council officers - all new appointments - go on TV to say that everything has changed since the case began. Everyone looks very earnest. Voices crack with compassion. Nothing essential changes".<ref>Ian Willmore writing in ''The Observer'', "[http://society.guardian.co.uk/climbie/comment/0,,882710,00.html An evasion of responsibility]", ''The Observer'', [[26 January]] [[2003]]. Retrieved on [[5 July]] [[2007]].</ref> == References == {{reflist|2}} == External links == *[http://www.victoria-climbie-inquiry.org.uk/ The Victoria Climbié Inquiry] • [http://www.victoria-climbie-inquiry.org.uk/Background/back_chron.htm Timeline] • [http://www.victoria-climbie-inquiry.org.uk/Evidence/Archive/latestp1.htm Evidence] • [http://www.victoria-climbie-inquiry.org.uk/News_Update/news_update.htm News] *[http://www.victoria-climbie-inquiry.org.uk/finreport/finreport.htm Laming report] • {{PDFlink|[http://www.victoria-climbie-inquiry.org.uk/finreport/report.pdf Laming report]|1.74&nbsp;[[Mebibyte|MiB]]<!-- application/pdf, 1831701 bytes -->}} • {{PDFlink|[http://www.victoria-climbie-inquiry.org.uk/finreport/summary-report.pdf Summary and recommendations]|314&nbsp;[[Kibibyte|KiB]]<!-- application/pdf, 322074 bytes -->}} *[http://news.bbc.co.uk/1/hi/in_depth/uk/2002/victoria_climbie_inquiry/default.stm BBC: Victoria Climbié inquiry] • [http://news.bbc.co.uk/1/hi/uk/2062590.stm Timeline] *[http://society.guardian.co.uk/climbie/0,10939,530323,00.html ''The Guardian'': The Climbié inquiry] • '''Timelines:''' [http://society.guardian.co.uk/climbie/story/0,10939,557475,00.html General] • [http://society.guardian.co.uk/climbie/story/0,,616574,00.html Inquiry phase one] • [http://society.guardian.co.uk/climbie/story/0,,637569,00.html Inquiry phase two] *[http://www.victoriaclimbietrust.org.uk/ Victoria Climbié Charitable Trust] • [http://www.victoria-climbie.org.uk/index.php Victoria Climbié Foundation UK] *[http://www.everychildmatters.gov.uk/ Every Child Matters] • [http://www.opsi.gov.uk/acts/acts2004/20040031.htm Children Act 2004] • [http://www.everychildmatters.gov.uk/deliveringservices/contactpoint/ ContactPoint] • [https://www.childrenscommissioner.org/ Office of the Children's Commissioner] {{DEFAULTSORT:Murder of Victoria Climbie}} [[Category:1991 births|Climbie, Victoria]] [[Category:2000 deaths|Climbie, Victoria]] [[Category:2000 crimes]] [[Category:2000 in London]] [[Category:British murdered children|Climbie, Victoria]] [[Category:Ivorian people|Climbie, Victoria]] [[Category:Public inquiries]] [[pt:Victoria Climbié]]