The Victoria Climbié Inquiry

Terms of Reference: To establish the circumstances leading to and surrounding the death of Victoria Climbié; to reach conclusions as to the circumstances leading to Victoria Climbié's death and make recommendations to the Secretary of State for Health and to the Secretary of State for the Home Department as to how such an event may, as far as possible, to be avoided in the future.


Chair: Lord Laming

Panel Members: Lord Laming was assisted by a team of expert advisers including specialist staff in paediatric medicine, nursing, social care and the police

Dates:

· Establishment: 20th April 2001

· Hearings: 31st May 2001 (preliminary hearing); 28th September 2001- 11th July 2002 (phase one- looking at the involvement of social services, the police, housing staff and health workers in Victoria's case); 15th March, 22nd March, 12th April, 19th April and 26th April 2002 (phase two- five seminars looking at the child protection system in general)

Report: 28th January 2003

To download report: http://www.victoria-climbie-inquiry.org.uk/finreport/finreport.htm


Description of the events which caused the public concern: Victoria Climbié died on 25th February 2000 and her carers, Marie-Therese Kouao and Carl Manning, were subsequently convicted on murder in January 2001. Victoria came into contact with four social services departments, three housing departments, two specialist child protection teams of the Metropolitan Police, two hospitals and a families centre managed by the NSPCC. As detailed in the Report, there was a catalogue of administrative, managerial and professional failures and there were a number of occasions upon which “the most minor and basic intervention on the part of the staff concerned could have made a material difference to the eventual outcome”.

Summary of report’s general recommendations:

In total there were 108 recommendations, 46 (designated ‘1’) to be implemented within 3 months, 36 (designated ‘2’) to be implemented within 6 months and the remainder (designated ‘3’) to be implemented within 2 years.

The Report outlined three areas of recommendation:

· “a fundamental change in the mind-set of managers in key public services, who must see their role in terms of the quality of services delivered at the front door rather than in administrating bureaucratic and sometimes self-serving procedures

· a clear and unambiguous line of managerial accountability both within and across public services

· the current arrangements of Area Child Protection Committees or any proposal for a national child protection agency, should be replaced by a new National Agency for children and families. This Agency should have powers to ensure that all of the key services affecting children and families - health, housing and police - carry out their duties in an efficient and effective way. The Chief Executive of this agency could undertake the functions of a Children's Commissioner for England. The Agency should report to a new ministerial committee for services to children, chaired by a minister of cabinet rank who would be responsible for ensuring that policies, legislation and departmental initiatives affecting children and families are properly considered, financed and co-ordinated. Similar arrangements need to operate at a local level.”

General recommendations:

Recommendation 1 With the support of the Prime Minister, a ministerial Children and Families Board should be established at the heart of government. The Board should be chaired by a minister of Cabinet rank and should have ministerial representation from government departments concerned with the welfare of children and families. (paragraph 17.97)

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Recommendation 2 The chief executive of a newly established National Agency for Children and Families will report to the ministerial Children and Families Board. The post of chief executive should incorporate the responsibilities of the post of a Children's Commissioner for England. (paragraph 17.97)

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Recommendation 3 The newly established National Agency for Children and Families should have the following responsibilities:

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  • to assess, and advise the ministerial Children and Families Board about, the impact on children and families of proposed changes in policy;
  • to scrutinise new legislation and guidance issued for this purpose;
  • to advise on the implementation of the UN Convention on the Rights of the Child;
  • to advise on setting nationally agreed outcomes for children and how they might best be achieved and monitored;
  • to ensure that legislation and policy are implemented at a local level and are monitored through its regional office network;
  • to report annually to Parliament on the quality and effectiveness of services to children and families, in particular on the safety of children. (paragraph 17.97)

Recommendation 4 The National Agency for Children and Families will operate through a regional structure which will ensure that legislation and policy are being implemented at a local level, as well as providing central government with up-to-date and reliable information about the quality and effectiveness of local services. (paragraph 17.97)

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Recommendation 5 The National Agency for Children and Families should, at their discretion, conduct serious case reviews (Part 8 reviews) or oversee the process if they decide to delegate this task to other agencies following the death or serious deliberate injury to a child known to the services. This task will be undertaken through the regional offices of the Agency with the authority vested in the National Agency for Children and Families to secure, scrutinise and analyse documents and to interview witnesses. I consider it advisable that these case reviews are published, and that additionally, on an annual basis, a report is produced collating the Part 8 review findings for that year. (paragraph 17.97)

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Recommendation 6 Each local authority with social services responsibilities must establish a Committee of Members for Children and Families with lay members drawn from the management committees of each of the key services. This Committee must ensure the services to children and families are properly co- ordinated and that the inter-agency dimension of this work is being managed effectively. (paragraph 17.97)

Recommendation 7 The local authority chief executive should chair a Management Board for Services to Children and Families which will report to the Member Committee referred to above. The Management Board for Services to Children and Families must include senior officers from each of the key agencies. The Management Board must also establish strong links with community-based organisations that make significant contributions to local services for children and families. The Board must ensure staff working in the key agencies are appropriately trained and are able to demonstrate competence in their respective tasks. It will be responsible for the work currently undertaken by the Area Child Protection Committee. (paragraph 17.97)
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Recommendation 8 The Management Board for Services to Children and Families must appoint a director responsible for ensuring that inter-agency arrangements are appropriate and effective, and for advising the Management Board for Services to Children and Families on the development of services to meet local need. Furthermore, each Management Board for Services to Children and Families should:

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  • establish reliable ways of assessing the needs and circumstances of children in their area, with particular reference to the needs of children who may be at risk of deliberate harm;
  • identify ways of establishing consultation groups of both children and adult users of services. (paragraph 17.97)

Recommendation 9 The budget contributed by each of the local agencies in support of vulnerable children and families should be identified by the Management Board for Services to Children and Families so that staff and resources can be used in the most flexible and effective way. (paragraph 17.97)
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Recommendation 10 As part of their work, the government inspectorates should inspect both the quality of the services delivered, and also the effectiveness of the inter-agency arrangements for the provision of services to children and families.

(paragraph 17.97)
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Recommendation 11 The Government should review the law regarding the registration of private foster carers.

(paragraph 17.97)
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Recommendation 12 Front-line staff in each of the agencies which regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded. This must include the child's name, address, age, the name of the child's primary carer, the child's GP, and the name of the child's school if the child is of school age. Gaps in this information should be passed on to the relevant authority in accordance with local arrangements. (paragraph 17.97)
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Recommendation 13 The Department of Health should amalgamate the current Working Together and the National Assessment Framework documents into one simplified document. The document should tackle the following six aspects in a clear and practical way:
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  • It must establish a 'common language' for use across all agencies to help those agencies to identify who they are concerned about, why they are concerned, who is best placed to respond to those concerns, and what outcome is being sought from any planned response.
  • It must disseminate a best practice approach by social services to receiving and managing information about children at the 'front door'.
  • It must make clear in cases that fall short of an immediately identifiable section 47 label that the seeking or refusal of parental permission must not restrict the initial information gathering and sharing. This should, if necessary, include talking to the child.
  • It must prescribe a clear step-by-step guide on how to manage a case through either a section 17 or a section 47 track, with built-in systems for case monitoring and review.
  • It must replace the child protection register with a more effective system. Case conferences should remain, but the focus must no longer be on whether to register or not. Instead, the focus should be on establishing an agreed plan to safeguard and promote the welfare of the particular child.
  • The new guidance should include some consistency in the application of both section 17 and section 47. (paragraph 17.111)

Recommendation 14 The National Agency for Children and Families should require each of the training bodies covering the services provided by doctors, nurses, teachers, police officers, officers working in housing departments, and social workers to demonstrate that effective joint working between each of these professional groups features in their national training programmes. (paragraph 17.114)
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Recommendation 15 The newly created local Management Boards for Services to Children and Families should be required to ensure training on an inter-agency basis is provided. The effectiveness of this should be evaluated by the government inspectorates. Staff working in the relevant agencies should be required to demonstrate that their practice with respect to inter-agency working is up to date by successfully completing appropriate training courses. (paragraph 17.114)
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Recommendation 16 The Government should issue guidance on the Data Protection Act 1998, the Human Rights Act 1998, and common law rules on confidentiality. The Government should issue guidance as and when these impact on the sharing of information between professional groups in circumstances where there are concerns about the welfare of children and families. (paragraph 17.116)

Recommendation 17 The Government should actively explore the benefit to children of setting up and operating a national children's database on all children under the age of 16. A feasibility study should be a prelude to a pilot study to explore its usefulness in strengthening the safeguards for children. (paragraph 17.121)
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