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FROM MARIA COLWELL TO VICTORIA CLIMBIE: REFLECTIONS ON
A GENERATION OF PUBLIC INQUIRIES INTO CHILD ABUSE
Plenary paper by Professor Nigel Parton for the BASPCAN conference, July 2003 (published in Child Abuse Review (2004), 13 (2), pp80-94)
In his statement to the House of Commons when presenting Lord Laming’s Inquiry Report into the death of Victoria Climbié, on 28 January 2003, the Secretary of State for Health, Alan Milburn, said:
It is an all too familiar cry. In the past few decades there have been dozens of inquiries into awful cases of child abuse and neglect. Each has called on us to learn the lesson of what went wrong. Indeed, there is a remarkable consistency in both what went wrong and what is advocated to put it right. Lord Laming’s Report goes further. It recognises that the search for a simple solution or a quick fix will not do. It is not just national standards, or proper training, or adequate resources, or local leadership, or new structures that are needed. It is all of these things. (my emphasis)
This theme, of the failure to learn the lessons of the many public inquiries over the previous thirty years, was a central one which was picked up in the ensuing House of Commons debate and in the media and press coverage of the publication of the report, both on 28 and 29 January 2003. It was as if the frontline professionals, and the key organisations and agencies who have responsibility for children and families were quite incapable of learning the lessons and, crucially, putting these into practice in such a way that such horrendous tragedies could be avoided. It is hoped by many, therefore, that the report by Lord Laming, and the changes brought about as a result, will mean that this will be the last report of its type.
In many respects, we can see the publication of this most recent child abuse inquiry report as the end of an era. It is now a generation since the publication of the first of these reports in 1974 into the care and supervision provided in relation to Maria Colwell, who had died in January of 1973. The intervening twenty-nine years have seen the publication of over seventy reports, which have not only been concerned with children who have died as a direct result of physical abuse and neglect, but have also included inquiries into abuse in residential and day care (Corby et al, 2001) and the apparent, over-intervention, of state agencies, the most infamous of which was that into the events of Cleveland in 1987 (Secretary of State, 1988).
In this paper, I wish to reflect on some of the changes we can identify over this thirty year period. More particularly, I intend to compare and contrast the Maria Colwell and Victoria Climbié inquiries. In doing so, I am reading the reports as being emblematic of their respective times. I will be reading them as particularly high profile instances of the contexts in which they are located. As such, they can be seen to provide fascinating insights into the changes we have lived through over this thirty year period. As I will point out, there are very many similarities between the two reports and the respective cases and the way they were handled. However, my central argument is that rather than concentrate on the similarities it is important to consider and analyse the differences. It is my view that these differences are crucial, both in terms of understanding the changes in the nature of practice and the contexts within which it is located, but also in terms of what might be done in the future. While my primary purpose is analytic, I will, by way of conclusion, try and identify some key themes which I feel might be helpful in informing how we might think about, reframe and reform policy and practice in the future.
What has clearly emerged, at least to us, is a failure of the system compounded of several factors of which the greatest and most obvious must be that of the lack of, or ineffectiveness of, communication and liaison. A system should so far as possible be able to absorb individual errors and yet function adequately (para. 240, 1974).
And more specifically:
Many of the mistakes made by individuals were either the result of, or contributed to, by inefficient systems operating in several different fields, notably training, administration, planning, liaison and supervision (para. 241, 1974).
Both inquiry reports identify a number of common themes: considerable confusion and a failure to communicate key information, so that as a consequence both children fell through the elaborate welfare net; there was very poor and often confusing recording of very basic information relating to visits, phone calls, conversations and messages passed between different professionals, and a general failure to use the case file in a productive and professional way; considerable failure to engage and communicate directly with the children themselves about their feelings and circumstances; there was considerable deceit on behalf of the key primary carers and insufficient critical analysis and scepticism on behalf of the professionals as to what was being told and being presented to them; and there was a severe lack of consistent and rigorous supervision. Both cases attracted considerable media attention and can be seen as not just politically sensitive but as posing fundamental questions about the
health and welfare systems available to children and families. It was the Maria Colwell inquiry that ushered in major practice changes following the DHSS circular in April 1974 and which in effect introduced the modern child protection system in this country, in terms of the establishment of what we now call Area Child Protection Committees, the institutionalisation of the case conference system and the establishment of child protection registers, as well as all the procedures which have been refined and updated over the subsequent thirty year period. Both inquiries seem to demonstrate failure and that ‘something needs to be done’. It is in this context that it is likely that the Laming Inquiry seems to be ushering in another major period of change.
Finally, both inquiries were established by the relevant Secretary of State. However, this is perhaps the first important area of difference, for whereas the Maria Colwell inquiry was set up by the Secretary of State for Social Services, the Victoria Climbié inquiry was set up by the Secretary of State for Health together with the Secretary of State at the Home Office. In effect, the latter was to conduct three parallel statutory inquiries in relation to local authority social services, health services as well as the police. Similarly, its terms of reference were somewhat broader, for rather than only being concerned with the circumstances leading to and surrounding the death of Victoria Climbié, the Inquiry was also required to make recommendations as to ‘how such an event may, as far as possible, be avoided in the future’. The Victoria Climbié inquiry thus had a much wider brief. I now want to look more explicitly at some of the key differences, beginning with the inquiry reports themselves.
the inquiry panel was set up with four assessors to help him with the task. It is a much bigger and more expensive operation. The counsel for the Maria Colwell inquiry consisted of two QCs and the inquiry team was supported by one secretary. Seven parties to the inquiry had legal representation.
In contrast, the inquiry staff for the Victoria Climbié consisted of: one secretary to the inquiry; one solicitor to the inquiry; three counsel to the inquiry; a secretariat consisting of seven people; a legal team consisting of thirteen people; two special advisors; two people listed as communications; and seven people as being provided by two separate groups of contractors; plus one person as sound. The legal representatives for the interested parties before the Victoria Climbié consisted of: four London boroughs; three health trusts; one health authority; the Metropolitan Police; the NSPCC; eight police officers; and one social worker. Added to this, there were twenty witnesses with legal representation. In the Maria Colwell inquiry: sixty- five witnesses were examined; there were five witnesses who gave expert evidence; and thirteen witnesses who provided statements which were read in whole or in part by the committee. In contrast, in the Victoria Climbié inquiry: 159 witnesses presented evidence both orally and in writing; 119 witnesses presented evidence in writing only; and just one witness provided oral evidence only; a total of 278 witnesses. In addition the Victoria Climbié inquiry – in order to address its recommendations for the future – organised five seminars which had 120 participants.
The Maria Colwell inquiry had its preliminary hearing on 24 August 1973 and then was sitting between 9 October 1973 and 7 December 1973. In contrast, the Victoria
Climbié inquiry had its preliminary hearing on 30 May 2001 and was formally opened on 26 September 2001, taking its final evidence on 31 July 2002, having been reconvened earlier that year. As already noted, the Victoria Climbié inquiry had a web site where all the evidence, both oral and written, to the inquiry was made available. In the case of the oral evidence it was available on the web within hours of it being presented and was available verbatim. The web site received around three million hits between 30 September 2001 and 30 September 2002 (2003 para. 1.48). It is also important to note that while there are a number of implicit recommendations within the Maria Colwell inquiry, the Victoria Climbié inquiry quite clearly specifies 108 recommendations of which 82, it argued, should be implemented within six months of publication.
There is also a much more personalised dimension to the Victoria Climbié inquiry. Not only were her parents present, with legal representation, throughout phase one of the inquiry, and present in the House of Commons when the Secretary of State, Alan Milburn, presented the inquiry report to parliament, but as the inquiry itself states:
It has felt as if Victoria has attended every step of this inquiry, and it has been my good fortune to have had the assistance of colleagues whose abilities have been matched by their commitment to the task of doing justice to Victoria’s memory and her enduring spirit, and to creating something positive from her suffering and ultimate death (para. 1.66).
And earlier:
smiling, enthusiastic little girl – brought to this country by a relative for ‘a better life’ – ended her days the victim of almost unimaginable cruelty. The horror of what happened to her during her last months was captured by Counsel to the Inquiry, Neil Garnham QC, who told the Inquiry: ‘The food would be cold and would be given to her on a piece of plastic while she was tied up in the bath. She would eat it like a dog, pushing her face to the plate. Except, of course, a dog is not usually tied up in a plastic bag full of its excrement. To say that Kouao and Manning treated Victoria like a dog would be wholly unfair; she was treated worse than a dog.’ 1.2 On 12 January 2001, Victoria’s great-aunt Marie-Therese Kouao and Karl John Manning were convicted of her murder.’
This much more personalised writing style in the Climbié inquiry report is particularly powerful in the way it contrasts the guilty and the innocent, and the way key actors were seen to have failed in key responsibilities. More particularly the inquiry report sees itself, partly a reflection of its much broader brief, as having a key mission on behalf of many children well beyond Victoria. Victoria is portrayed as a symbol of what can happen to children when they are not appropriately protected and cared for. For example, if we look at the second half of paragraph 1.66 quoted above, it reads:
... throughout, we have all kept a clear focus on the facts and on finding out what happened to Victoria, why things happened in the way they did and how such terrible events may be prevented in the future. I am convinced that the
answer lies in doing relatively straightforward things well. Adhering to this principle will have a significant impact on the lives of vulnerable children.
The Victoria Climbié inquiry provides a coherent, convincing and powerful account of what happened to Victoria, how she was failed and how this can be avoided in the future. While the account in the Maria Colwell inquiry is of a similar nature, it is also much more equivocal. This is in part because the inquiry report has within it the minority report written by one of the inquiry team, Olive Stevenson. It is not that the report has a major dispute over the facts, but it is in their interpretation, particularly in relation to some of the early decisions leading up to why Maria was returned home, from her foster carers, that there is something of a difference of opinion. In her minority report, included as chapter five in the Maria Colwell report, Olive Stevenson writes as follows:
As a social worker, my education and experience has taught me that in such matters, there is no one truth; in considering the subtleties of human emotions everyone is subjective. One’s feelings, attitudes and experience colour one’s perception. This is as true for me as it is for my colleagues. And when one is dealing with events now some time in the past, drawing to a large extent on records for evidence, and inevitably affected by the eventual tragedy, the probability of distortion in interpretation is all the greater’ (para. 2.47).
And later:
attention. More specifically, a whole variety of procedures and systems have been set up particularly to enhance inter-agency and inter-professional coordination in order to share information and to ensure that children do not fall through the health and welfare nets with such tragic consequences. Similar comments, about the system, are clearly reported in relation to Victoria Climbié. There is, of course, an important difference. Whereas the Maria Colwell inquiry can be seen to have been a major factor in the introduction and subsequent refinement of child protection systems in this country, and which are seen as the major vehicle by which such tragedies might be avoided, it is these systems which are in part the subject of the Victoria Climbié inquiry. When the latter says: ‘The suffering and death of Victoria was a gross failure of the system and was inexcusable’ (para. 1.18), by implication it is these child protection systems which are seen as much a part of the problem as the solution. Of course, the intervening thirty years have witnessed an exponential explosion of actual and potential child abuse referrals and allegations of ‘significant harm’ coming the way of certain agencies, particularly social service departments. While we have no figures in this country, statistics from North America and Australia are instructive. In the US the number of child abuse and neglect reports to statutory child welfare agencies increased from 9,563 in 1967 to 669,000 in 1976, and to over three million in the 1990s. In the State of Victoria in Australia, the figure increased from 517 in 1977/8 to 26,622 by the mid 1990s. It is not surprising, therefore, if policies and procedures were developed in the UK to try to allocate very scarce resources in the context of this huge potential growth in awareness and need. It is particularly ironic that in the Victoria Climbié inquiry the allegations of child abuse had the effect of skewing the way the case was handled procedurally. In the early weeks of the Haringey involvement there was a major issue about housing and how Marie-Therese
Kouao and Karl Manning were dealing with Victoria’s behaviour, together with the sleeping arrangements provided for her. Essentially, Kouao was demanding new accommodation. In paragraph 6.375 we are told:
During the course of the conversation Ms Arthurworrey made the point that the council “only accommodated children who were at risk of significant harm” and that Victoria was not, in the council’s view, at such risk. It is perhaps no coincidence that the next time Ms Arthurworrey saw Kouao was because of Kouao making allegations which, if true, would have meant that Victoria was at very real risk.
Just four days later Marie-Therese Kouao telephoned the social worker making allegations about the sexual abuse of Victoria by Karl Manning.
I am not suggesting that the systems and procedures that were in place in Haringey were appropriate. What I am trying to demonstrate, however, is that the systems, which the two inquiries were critically reporting on were very different. Essentially, in the Victoria Climbié inquiry many of the systems which were seen as so wanting, had been set up following the Maria Colwell inquiry. It is in this context that I am suggesting that such systems are therefore seen as much a part of the problem as the solution, and as contributing to the tragedy which was to unfold.
I now want to look at a series of discrete but interrelated issues which I feel crucially differentiate the inquiry reports and the events and contexts within which they are located.
name, a known mother, an address and a school. In this respect she could be seen to have a clear identity and location.
Hardly any of these characteristics were evident in relation to Victoria Climbié. While the two children were of similar age and suffered similar injuries, in many respects these are the only things they have in common. It was only after Victoria’s death that her ‘real’ identity became known. Similarly, it was only after her death that it became apparent that Marie-Therese Kouao was not her real mother but was ‘a great aunt’ and that her parents lived in the Ivory Coast. There are major issues about her national identity, the nature of her entry into the UK, whether she ever had a permanent address, the fact that she did not have a school or a GP, and that on numerous occasions the various health and welfare departments did not realise they were actually dealing with the same child and ‘family’. Who had ‘parental responsibility’ was particularly confusing and was never clearly addressed or resolved within the inquiry report. In many ways all of these important issues reflect many of the significant social and cultural changes that have been going on in this country during the intervening thirty years.
In the Maria Colwell inquiry a major issues was concerned with trying to judge how significant the issue of the ‘blood tie’ was in relation to the decision making, and how this was appropriately addressed. Such issues now seem remarkably old fashioned. There is now considerable variation and complexity in household and family structure and relationships, such that the model of the traditional nuclear family no longer seems to represent the majority of the population. As a consequence we now usually refer the ‘family’ as opposed to the family. Such changes pose major
challenges for professionals and agencies whose prime responsibility is to children and families in the context of these huge variations (Featherstone, 2003).
The other major area for social change over the intervening thirty years is probably concerned with globalisation. Issues related to and arising from this are core to the Victoria Climbié in a way which is hardly evident with Maria Colwell. While both reports discuss the importance of cultural differences between the workers and the adults and children with whom they work, the way this is discussed is very different. For example, in Olive Stevenson’s minority report she discusses (see in particular para. 285) the cultural differences that were possible in the way Mr Keppel, Maria’s stepfather, made sense of and responded to Maria’s behaviour compared to the way the professionals might have analysed this.
It is not in the least uncommon for men and women from such backgrounds to view with astonishment the notion of problems of emotional adjustment. And Mr Keppel was quite right in reminding Miss Lees (the social worker) that in some cultures children are ‘borrowed and returned’ between relatives, with no fuss or bother!... Furthermore, even in our own society, it is not uncommon for men to leave such matters ‘to the wife’ and for both men and women to have difficulty in imagining in advance what difficulties may arise’ (para. 2.85).
The cultural differences are seen essentially in terms of social class and gender. I find it notable that Diana Lees, Maria’s social worker, when she left social work, took up a post with the Foreign Office. While not necessarily typical we are pointing here to
The impact of increased global mobility, more specifically the rapid increase in asylum-seeking families, together with the diverse backgrounds of the workers themselves increasingly seems to characterise work in many metropolitan areas. It has a particular impact on the nature, stability and cohesion of local communities. It is notable that, compared to the Maria Colwell case, no referrals are noted in the Victoria Climbié case from neighbours or other members of the community apart from the ‘child minder’ Mrs Cameron. We are not simply talking about diversity here but incredible complexity and fluidity. Not only does it pose major linguistic challenges but it poses major challenges for statutory departments in relation to the familial and cultural identities of those with whom they work and to whom they have responsibility. Issues around racism are clearly important here, however they cannot be reduced to a simple black and white community and cultural divide.
Expert Knowledge
A major theme identified throughout the thirty year period has been the importance of various professionals sharing not just factual information but also their respective expertise. It is argued that each organisation and profession has particular expertise which needs to be mutually understood and worked with in relation to each case. This is particularly illustrated in relation to the role of the medical profession. There has been a strong feeling that medical expertise is important in relation to identifying problems in children’s health and development and to help make sense of particular behaviours. This was something clearly underlined in the Maria Colwell inquiry. For example:
It is obvious to us, as was Dr White Franklin’s (an expert witness to the inquiry) opinion that the child had very strong feelings and was demonstrating them in a significant way... what we do consider wholly wrong is that no effort, even at that late stage, was made to obtain a medical opinion as to the depth and significance of Maria’s continuing protests (para. 66).
A major problem identified in the Maria Colwell inquiry was the failure to persuade Maria’s mother to get her medically examined at certain key times when there seemed to be evidence of injuries. She was not medically examined, her injuries were not treated, and crucially the nature and possible implications of these injuries were not included as part of the overall picture. Such physical signs were seen as a key indicator of what had previously been called the ‘battered child syndrome’ but which was little recognised by professionals (see Kemp et al, 1962). A major element of the subsequent DHSS circulars was to bring this phenomenon to professional attention and try to encourage professionals, particularly social workers, to recognise a syndrome which had previously gone unrecognised. Medical diagnosis was seen not simply as a part of the clinical picture but a key mechanism for raising professional and public awareness. Medical diagnosis was seen as something to be encouraged and developed and was not seen as problematic in other ways.
The situation in the Victoria Climbié case is, however, very different, where two hospitals played a significant role. A major issue in the inquiry is to establish the nature of the clinical symptoms that were being presented, and in particular whether and how far these could be seen as ‘scabies’. There are numerous points in the report
