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Learning from the Victoria Climbie Inquiry 

By Rachel Tate

 Darran Youell

 Nick Wells

 Fiona Turner

Neill Tunnicliffe

Clare Wilde

Question 1 - Response to the failings of social services

From the scrutinising of Lord Laming’s report into the death of Victoria Climbie in 2000 it would appear that this child was sadly let down by a system (designed by adults) to protect children vulnerable to the system and abuse.

It is imperative that as student social workers we recognise that both law and due process should protect children…

The Victoria Climbie Inquiry report showed that the system failed comprehensively, because of ill-trained and overworked staff,who were unsupported by their managers or more senior staff in their organisations, and because of senior staff faing to take responsibility for the quality of children's services in the organisation.Safeguarding Children showed that, although Victoria’s was an extreme case, there were issues emerging from it that are also relevant elsewhere.

• Several departments operated with outdated (paper) filing systems
  
• An adoption of a policy of routine, ‘drift’ and assumption.
  
• A fundamental loss of focus as to what represented a child in need and a child at risk of abuse, or indeed, suffering abuse. 
  
• A failure to act swiftly and appropriately.
  
• A failure by senior practitioners and managers to address flaws in departments and their practices.
  
• There was a recognised failure by managers/supervisors to use supervision both appropriately and effectively.

  There had already been several high profile cases of deaths of children due to abuse/neglect in the immediate vicinity:

• 1985 - ‘ A child in Trust’ report upon the death of jasmine Beckford  (London Borough of Brent).
  
• 1987 – ‘ Whose Child’ a report upon the death of Tyra Hendly (London Borough of Lambeth).
  
• 1987 – ‘ A Child in Mind’ reporting upon the death of Kimberly Carlile (London Borough of Greenwich).
  
• 1988 – ‘ The Report of the Inquiry into Child Abuse in Cleveland’                                                               

·        The impact of these shocking cases was profound upon child protection teams countrywide and the duty towards children in need escalated.  Indeed, the Social Services Inspectorate, in response to inspection of social services in Great Britain, concluded that authorities were in need of a more structured and systematic approach (Fowler J. 2004). 

·        1999 saw the publishing by The Department of Health’s  ‘Working Together to Safeguard Children’

·        1989 saw the publishing of the Children Act

·        1988 saw the Department of Health publish ‘Protecting Children. A Guide for Social Workers undertaking a Comprehensive Assessment’ 

·        Already in place was The Child Care Act 1980 that placed heavy emphasis upon protecting children at risk.

Over arching legislation cannot be ignored either.  The United Nations Convention on the rights of the Child had identified fundamental protective measures.

We see also the failings of the local health services and child-minders to report or at least pursue some kind of child-protection procedure.  Although some steps were considered due to personal conviction of individuals, it would appear that the spectre of ignorance and a culture of assumption and drift prevailed.  

Question 2 - Look at material since Victoria’s death.

The Every Child Matters: Change for Children program has been formulated to address the issues of social care, welfare and protection of children. The aim is to put in place a national framework to support the linking up of the full range of children’s services so that all children can achieve the every child matters outcomes. These outcomes are:

1. Be Healthy- Physically healthy, Mentally and emotionally healthy, sexually healthy, Healthy Lifestyles and chose not to take illegal drugs
   
2. Stay Safe- Safe from maltreatment, neglect, violence and sexual. exploitation, Safe from accidental injury and death, safe from bullying and discrimination, safe from crime and anti-social behaviour in and out of school and Have security, stability and are cared for.
   
3. Enjoy and Achieve- ready for school, attend and enjoy school, achieve stretching national educational standards at primary school, achieve stretching national educational standards at secondary school.
   
4. Make a Positive Contribution- engage in decision making and support the community and environment, Engage in law abiding and positive behaviour in and out of school, Develop positive relationships and choose not to bully or discriminate, Develop self-confidence and successfully deal with significant life changes and challenges, Develop enterprising behaviour.
   
5. Achieve Economic Well- Being- engage in further education, employment or training on leaving school, Ready for employment, Live in decent homes and suitable communities, Access to transport and material goods, and Live in households free from low income.

10 key elements of national framework to achieve this are:

1. Duty to cooperate-promote well being
   
2. Duty to make arrangements to safeguard and promote welfare
   
3. Development of statutory local safeguarding children’s boards
   
4. Appointment of local directors
   
5. National Service Framework for children
   
6. Outcomes Framework
   
7. Develop integrated inspection framework
   
8. Appointment of children’s commissioner
   
9. Develop common assessment framework
   
10. Reform workforce- develop skills ensure staffing levels

Following the tragic case of Victoria, there have been many steps taken in regard to the protection of children to stop this from ever happening again. The Children Act 2004 has been a key piece of legislation that links to the ‘change for children programme’ that is currently in operation and contributes to ‘delivering genuine change for children, so that the outcomes for every child are improved’. (www.doh.gov.uk 24/01/06.)

Within the Children Act 2004 there are many parts that focus on change for children, e.g.: ‘A new children’s commissioner’ (part 1), ‘local safeguarding children boards’ (part 2) and  ‘stronger requirements to manage private fostering schemes’ (part 5) are a few examples of future change. (www.dfes.gov.uk/ISA/childrenAct/summary.cfm 23/01/06.) In implementing the Act and its new key parts, it identifies the following:

 ‘Overall aim is to encourage integrated planning, commissioning and delivery of services as well as improve multi disciplinary working, remove duplication, increase accountability and improve the coordination of individual and joint inspections in local authorities. The legislation is enabling rather than prescriptive and provides local authorities with a considerable amount of flexibility in the way they implement its provisions.’ (www.dfes.gov.uk/publications/children act report 23/01/06.)

However, within this future change other work since Victoria‘s death can be seen to be providing a contribution, i.e.: ‘Working Together To Safeguard Children’ (1999) is another piece of work that has been developed. An example of this new work is the booklet ‘What to do if you’re worried a child is being abused’, (Department of Health May 2003) and this is a primary level intervention which links into the ‘Local Safeguarding Children Boards’ that are clearly defined (as mentioned earlier) in the Children Act 2004.

Overall, it can be seen that the Children Act 2004 offers clear guidance to further improve the protection of children and some of the areas within this guidance can be seen in earlier legislation, policy and procedures.

Question 3 -Anti-Discriminatory Practice

Introduction

Following the inquiry into the tragic circumstances surrounding the death of Victoria Climbie, and the publication of several key recommendations, Social Service departments nationally were made to evaluate their own qualities of practice.

One of the areas of practice that was raised as a focus for concern was anti-discriminatory practice (ADP).

I will explain the meanings of discrimination and ADP, put these into context of children’s services, look specifically at the Victoria Climbie case and finish by clarifying the link between ADP and good social work practice.

What is discrimination and ADP?

Discrimination is when a person (or group of people) is treated less favourably than others would be treated in the same circumstances.

There are many forms of discrimination, and these can be based on race, gender or age to name but a few. There are a number of pieces of legislation in place to protect against discrimination.

For example, to treat someone less favourably because of their race, colour, nationality, or ethnic or national origin, is illegal under the Race Relations Act 1976.

ADP is a process which social workers should use, to work towards the reduction of discrimination by individuals and institutions. This means that not only should social workers be non-discriminatory in their own practice but they should also challenge any discriminatory practice they encounter.

This can even mean challenging their colleagues and employers.

ADP and Children’s Services.

Children’s services are about the provision of services to the child. Not the white child, or the black child, just the child. Discrimination has no place in children’s services, and by using ADP a social worker challenges any form of discrimination they encounter.

Under The Children Act 1989, the welfare of the child is paramount, so when it comes to issues of children’s services, an awareness and understanding of cultural differences is required, but this shouldn’t be a blockage or a reason for delay in the protection of the child.

A child’s culture is important, but its safety and wellbeing are of higher importance.

The “Working with Diversity” section of the Victoria Climbie Inquiry Final Report states,

“The basic requirement that children are kept safe is universal and cuts across cultural boundaries…Cultural heritage cannot take precedence over standards of childcare embodied in the law” (Lord Laming 2003a)

ADP and Victoria Climbie

With the application of ADP, by all professionals that had dealings with Victoria, the outcomes for her may have been entirely different.

For example, if the social worker had taken an anti-discriminatory approach to her assessment of Victoria’s situation she would not have made the assumptions detailed in the Inquiry Final Report, i.e. Victoria standing to attention in front of Kouao was “just a cultural thing” (Lord Laming 2003a) Or, if the medical staff had not made discriminatory assumptions regarding the marks on Victoria’s body, i.e. children who have grown up in Africa can be expected to have more marks on their bodies. (Lord Laming 2003a)

Victoria’s desperate need for help may well have been spotted, and acted upon, earlier.

Making assumptions based on little cultural knowledge was not only discriminatory, but also deprived Victoria of her right to fair and equal assessment and access to services.

ADP and Good Practice

As we have seen, discriminatory practice can have the most dreadful of outcomes.

By practicing in an ADP way, as social workers, we are not only acting in the best interests of our service-users but are also ensuring that discrimination is gradually being eliminated from their, already difficult lives.

I will finish with a quote from the Victoria Climbie Inquiry Final Report

“Safeguards must be in place to ensure that skin colour does not influence either the assessment or the quality of services delivered” (Lord Laming 2003a)

Question 4 - Lessons to be learnt from Victoria Climbie inquest

Following the death of Victoria Climbié and the subsequent inquest, Lord Laming’s report prompted the Children Act 1989 to be re-structured as the case highlighted the lack of communication between agencies, professionals and team members involved with the incident. The agencies involved had different interpretations of legislation; while resources allocated and staff management varied greatly. The Local Authority’s training, according to the report, was not up to date when dealing with child protection cases.

Victoria’s death is not the first to be linked with terrible mistakes; cases such as Jasmine Beckford and Kimberley Carlile are two more examples from an unacceptably long list, however improvements have been made over the years and the number of children on the child protection register has decreased. In 1997/98, the Department of Health reported that there were 31,600 children on the child protection register (the figure represents 28 children per 10,000 population under 18 years). In 2001 26,800 children and young people were on the register (the figure represents 24 children per 10,000 population under 18 years).

Lord Laming recommended that a national database for children under 16 needed to be set up, this is being implemented by the Government’s plans to introduce a National Information Sharing Index in all local authority by 2008, this will enable all agencies involved in delivery services to children to have quick access to shared information. Although set up cost is high (The Government estimates £224 million), money wasted from agencies trying to contact each other could be saved. Perhaps if this was already running, Victoria’s history could have been seen quicker and the outcome may have been different.

Multi agency work with health and educational teams allows different approaches to be considered and means the team addresses the holistic needs of a child. Communication needs to be in understandable language but also it must be remembered that action can speak louder than words.

Victoria was a child in need. There is a ‘Framework for the assessment of children in need and their families’ (Department of Health et al 2000) I have looked at this Framework and think it is essential for good practice for all professionals involved in assessing children in need.

When assessing a child in need there are 3 areas to take into account:

1. Child’s developmental needs – Victoria’s SW should have looked at her health, education, emotional and behavioural development, identity, family and social relationships, social presentation and self-care skills
   
2. Parenting capacity – Victoria’s SW should have looked to see if parents were meeting Victoria’s needs of: basic care, ensuring her safety, emotional warmth, stimulation, guidance and boundaries and stability
   
3. Family and environmental factors – Victoria’s SW looked at housing issues but also should have looked at family history and functioning, wider family, employment, income, family’s social integration and community resources

The Assessment Framework is child-centred, as we should always ensure that the child is kept in focus. The framework provides a good way of gathering information to analyse. We need to look at all the factors and their impact on the welfare of the child.

Using a child centred approach

• As the assessment is child centred it is important to communicate with the child to assess their needs. Use effective methods of communication. In Victoria’s case they should have got an interpreter.
  
•  It is important to build a rapport to gain the child’s trust so that they feel accepted.
  
• Parental presence can create problems if the parent seems to be controlling the child. Look at parent/child interaction and assess whether the parent should be present.
  
• Create a safe space where the child feels able to express their needs. Careful consideration should be given to the place where interviews with the child are carried out.
  
• We must ascertain the child’s views and feelings and reassure the child that their views are important

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