Examination of Witness (Questions 1-19)
THURSDAY 27 MARCH 2003
LORD LAMING
Chairman
1. Can I welcome you to this session of the
Committee. I particularly welcome you, Lord Laming. We are very
grateful for your cooperation with this inquiry. Perhaps it would
be appropriate at this stage for the Committee to place on record
our compassion for Victoria and her parents. Once again, thank
you, Lord Laming, for coming before us and your willingness to
give evidence today. I wonder if you would be willing to introduce
yourself, and in doing so perhaps say a little bit about your
own background in social work. Obviously you have had many, many
years of experience and although there are some of us who do know
you there are others who perhaps do not know your background,
which is very relevant to the issues we are going to talk about
today.
(Lord Laming) Thank you very much indeed,
Chairman, and I am very grateful for the invitation to come to
your Committee and very grateful for the interest that your Committee
is showing in the Report and in the wider issues that are raised
in the Report. I am Herbert Laming. I started my career in Social
Services in 1961 (which I guess you can tell by my appearance).
I was in Hertfordshire for 20 years, 16 of those years as the
Director of Social Services, having previously been the Deputy
Director of Social Services. From 1991 to 1998 I was the Chief
Inspector of Social Services in the Department of Health.
2. Some of us of a certain vintage know that
before 1971 Social Services were divided into three elements.
(Lord Laming) Yes.
3. In which element was your experience prior
to this?
(Lord Laming) I started off in the Probation Service
and then I trained as a psychiatric social worker.
4. As general background information, could
you say a little bit about the colleagues who worked with you
on the inquiry team and their backgrounds?
(Lord Laming) I was very keen that I should have four
professional assessors who not only were very experienced in their
respective fields but that they had current day by day involvement
with service delivery. You will appreciate, Chairman, that my
experience in direct involvement in service delivery is some years
ago and I wanted to make sure that I had with me people who had
a real vital understanding of what it is like to be in the front
line. I had first of all Dr Nellie Ajade who is a consultant paediatrician
working in Kent but very much involved in day by day paediatric
medicine. Mrs Donna Kinnair who is a nurse manager based in Southwark.
Mr John Fox who is a detective chief superintendent inspector
based in Hampshire but with responsibilities for special inquiries
which involve inquiries into deliberate harm of children. Mr Nigel
Richardson who was the head of the Children's Services in North
Lincolnshire but who has recently been made Director of Social
Services and Housing there.
5. Thank you. That is very helpful. Have you
had—other than the statement made by the Secretary of State
at the time of the publication of the Report—either formally
or informally any feedback on the Government's views on the recommendations
that you have made?
(Lord Laming) No, not at all. I think it is right
to say that the Government ministers behaved impeccably throughout
this inquiry and at no time during the inquiry did they attempt
either directly or indirectly to feed any information to the inquiry.
I was absolutely committed to ensuring that the inquiry was not
only independent but also transparent and the only evidence that
was considered was the evidence that was taken in the Committee
room and which appeared by eight o'clock each evening on the website.
The first time the ministers saw the Report was when it was printed
and the discussion we had was only about the publication arrangements
and since then I have had no discussions with them, although I
have since done some briefings to their officials.
Mr Amess
6. Lord Laming, your Report—as far as
I am concerned as an individual member of Parliament—has
been a great education for me. For instance, I just had no idea
that on average 80 children die every year as a result of abuse
and to think that there have been 70 public inquiries since 1945
for me the crux of this whole issue is "Here we go again.
I know we are talking about something in 2000, another inquiry.
What is different?" We have Dennis O'Neil in 1945, Maria
Colwell in 1973, Jasmine Beckford in 1984, Tyra Henry in 1984,
Kimberley Carlile in 1986, Doreen Mason in 1987, Leanne White
in 1992, Rickie Neave in 1994, Chelsea Brown in 1999, Victoria
Climbié in 2000, Lauren Wright in 2000, Ainlee Walker in
2002. All of these have had learned people such as yourself conduct
inquiries, spend a huge amount of time, make all these recommendations
and yet this sort of catastrophe meltdown continues. The question
I wish to put to you initially is, what do you think is going
to be different this time? I am not entirely being critical because
I am sure you will have an answer, but why did you appear not
to have undertaken detailed scrutiny of the past legacy of these
various inquiries?
(Lord Laming) Thank you for you confidence,
Mr Amess, that I have an answer; I hope that I will not disappoint
you. First of all, you will be perhaps interested to know that
I have read every one of those inquiry reports that you referred
to from cover to cover. I did that not in relation to this inquiry
but it was part of my duty to read those reports and be familiar
with them because of my past responsibilities. Of course, having
been invited or persuaded—whichever you choose—to
chair this inquiry, I re-visited them. I recognize that there
is a certain amount of duplication in the recommendations in those
reports and it is dispiriting that there has to be another inquiry
of this kind. The reason why I was persuaded—or agreed—to
chair the inquiry was because ministers felt that because Victoria
was known from the second day that she was in this country to
four social services departments, three housing departments, two
specialist child protection teams in the Metropolitan police,
was admitted to two different hospitals because of suspected deliberate
harm and was referred to a unit managed by the NSPCC, it was clear
that there needed to be a more fundamental look at why this happened
in this day and age, with our background, with all those reports
that you have referred to, with the Children Act of 1989. I think
it was for that reason that the Government decided to make this
inquiry different from others. In fact, I was told it was unique
in that it was set up under three different Acts of Parliament—as
you know—and therefore gave me the opportunity to look at
the way in which not just one agency had discharged its duties,
but the way in which all of the agencies had discharged their
duties. The recommendations are, I hope, geared towards improving
the system as a whole rather than improving the performance of
one particular department, whether it be social services, the
health service or the police service. So the recommendations that
I have made are not based upon more exhortation that people should
talk to each other better, that case records should be better,
that people should collaborate more fully and more effectively.
That is all true, and it is sad to say that I had to make recommendations
of that kind. However, what I hope that the Report has done is
to address something which is much more fundamental. It is no
use Parliament producing good legislation—and I believe
the Children Act is basically sound legislation—if Parliament
cannot be sure that that legislation is actually implemented at
the front door. That is what the acid test is about. It is not
about whether or not the legislation is good; it is about whether
or not children and families get a good service. I believe that
there is a yawning gap at the present time between the aspirations
and expectations of Parliament and the certainty of what is delivered
at the front door. That must be changed. What I am looking for
is a system where there is greater accountability at all levels,
where there is transparency within the system and where there
are no hiding places for people who have managerial responsibility
to actually ensure that services that are delivered are up to
a proper standard. If those principles actually were operating
in the system then I believe that there is a real prospect that
the need for inquiries in the future would not be added to the
list that you have already set out. Of course it is not possible
for services to protect children that are not known to them, but
it certainly is possible for services to protect children when
they have been referred to them.
7. Can I press you further on the questions
I asked you. It is wonderful that you have read all these reports.
I understand what you say about the three Acts and the terms of
reference from the Government, but I ask you again why, in terms
of your recommendations, did you not undertake detailed scrutiny
of the past inquiries? I just cannot believe how the whole thing
went unbelievably wrong. It does not seem to be that anything
worked; a complete disaster. Surely to goodness—when all
these children have been murdered and we have had the inquiries
and so on—you would have had said to your colleagues that
we have to learn from all the mistakes and in the recommendations
this is what we are going to go for. Why did you not take that
approach?
(Lord Laming) I find that question rather perplexing.
It may be that is an indication that the Report is not as well
written as some people have claimed it to be. I thought the Report
was absolutely clear that there are lessons that have to be learned
from previous inquiries and that mere exhortation to do better
is not going to meet the need and therefore something much more
fundamental is necessary. Had I not read those reports and had
I not considered them during the course of this inquiry then of
course it may be that I would come out with a recommendation that
would have been bland, well-intentioned and earnest but which
would not have made a difference. The recommendations that I have
made I hope are somewhat more substantial than perhaps you imply.
8. Before I move on to the next question, are
you telling the Committee that you are confident that as a result
of this inquiry your recommendations and your suggestions will
be acted upon and as a result of that in years to come there will
not be the Health Select Committee with someone like you sitting
before them, reading yet a further list? Are you absolutely confident—because
you yourself are going to continue to take a real interest in
this and keep pushing to ensure that your work is not wasted,
gathering dust—that we will never have to go through this
sort of inquiry again?
(Lord Laming) I have absolutely no confidence because
I have no influence on the matter. I produce the Report which
I then pass to the Government. It is entirely a matter for the
Government, and maybe your Committee could play some much more
substantial role than I can play in influencing those matters.
What I believe strongly is that there are certain principles in
the Report about clarity of purpose, about ensuring that legislation
is implemented, about making sure that Parliament understands
the reality of the quality of services which are being delivered
at local level, about making sure that the aspirations of Parliament
are being delivered. I think if the Government chose to go a different
route to achieve those objectives I would have no real concern
in that I am not sufficiently confident in myself or arrogant
to believe there is only one way to achieve that end result. But
if those principles which I hold dear in an open society are not
addressed, then I think there is every likelihood that there will
be more inquiries of the kind that I have just spent a long time
chairing.
9. Thank you for your advice. We will take it.
We will do our best. As you know, Parliament is full of good intentions.
When these things are central in the news we are very pro-active;
if you look at the list it is amazing how soon we forget. We are
now talking about a tragedy three years ago. Moving on to the
second question, when you looked at strengthening safeguards to
protect our children you suggested this novel approach by organising
a series of seminars with invited participants. Would you explain
to the Committee why you took this approach and on what basis
you decided—presumably it was on advice—that you would
invite these particular participants?
(Lord Laming) The terms of reference required the
inquiry not just to look back at what happened to Victoria and
to understand how it happened and why Victoria was not properly
protected, but also to look forward so that as far as humanly
possible a tragedy of this kind does not happen again. I felt
it was very important that our recommendations should not be based
upon what happened to one child or on what happened in one part
of north London because it seemed to me that hard cases make bad
law, if I can put it that way. It was essential that we devised
a device that would enable us to test out the matters that had
arisen during Phase One in a much wider way with a wider range
of people. But, of course, a number of people who submitted evidence
to the inquiry did not confine themselves to the terms of reference
and would have wished us to look at the whole of children's services,
the Children Act and perhaps behave like a royal commission which
we were not. It was a difficult matter to make sure that we drew
together people from across the country, from a wide range of
backgrounds, a wide range of experience, but that we kept the
issues to be talked about and to be discussed and examined within
our terms of reference and not be allowed to stray into other
fields. We were rigorous about that. Actually, it was not that
difficult to find the people; there were plenty of volunteers
for which I was most grateful. What we did was to identify five
particular aspects of the issues that had arisen in Phase One
and to ensure that we had a geographical spread, a spread of political
interests, a spread of experience, and I hoped that we achieved
that. What was, I think, the most compelling point that emerged
from the seminars was that many of the issues that had arisen
in Victoria's case actually were issues that caused a matter of
general concern across the country, and it is because of that
general concern that I think the recommendations in this Report
need to be taken that much more seriously.
10. Was the seminar approach a selective one?
I suppose I am asking you, if you were given the opportunity again—God
willing no-one will have to—to conduct an inquiry, would
you still pursue that approach? Do you regard it as the correct
way to deal with this matter? Surely a broader investigative approach
might have suggested far wider participants and evidence seeking.
In other words, I suppose I am questioning your methodology.
(Lord Laming) Yes, and not unreasonably so if I may
say so. I think there are real issues about this and I think that
you have to strike a balance between a reasonable examination
of the issues and the amount of time and effort and expense that
would be necessary to go down other routes. Frankly, this inquiry
could have lasted for many years. This inquiry turned out to be
very, very much larger in terms of the number of people that we
had to see in Phase One. When I took the inquiry on it was not,
I think, unreasonable at the time for people to think that because
Victoria had been alive in this country for only ten to eleven
months we would need to see something like 30 witnesses. We took
277 witness statements. Just think of the number of people that
could have intervened in Victoria's life. When it came to Phase
Two this could have been a life time's work. I did not think that
the issues that were being raised were issues that actually could
be taken at a relaxed pace. I thought it was absolutely essential
that we got this Report produced in a time when the issues were
still fresh in people's minds, when there was the possibility
of actually taking action that would prevent other tragedies of
this kind. Mr Amess, you very helpfully referred to two deaths
of children that actually occurred while the inquiry was sitting.
I know nothing more about those cases than I read in the media,
so I do not want to give the impression that I know anything more
than a member of the public knows about it. What I would say is
that if this is happening and if there is a fear that the system
is not working, then it seemed to me that there was a need to
focus the mind very carefully to get ahead on the issues and produce
a Report which I hope is implementable and implementable quickly.
Eighty-nine of the recommendations should be implemented, in my
view, within six months. I regard this as a really, really serious
matter, where there is a need for this issue to be gripped or
grasped—whichever way you want to put it—and to be
followed through with determination and resolution. I hope that
the example that I have tried to set is an example that others—including,
if I may say, Chairman, your Committee—will actually follow
through.
11. My final point to you—if you think
I am naive tell me so—is that you and your colleagues, having
listened to all the evidence and reflected on it, are you still
not shocked that everything went wrong in the way it did? Incompetence
beyond belief.
(Lord Laming) I do not regard that in the least bit
naive. I actually regard that as the very reason—and I am
very grateful for the question—why we need to take this
seriously. It is the very reason why these issues need to be addressed
urgently. Had this tragedy of Victoria Climbieé been because
one doctor, one social worker, one police officer, had failed
to see one telling sign indicating deliberate harm, frankly there
is no system in the world that can prevent that; any one of us
can make mistakes. When I look back over my years of practice
in social work I well recognise the mistakes that I have made
and I am sure there would be plenty of people who would like to
come here—given the opportunity—to highlight some
of them. However, when you get the whole of the system engaged,
when the second day this child was in this country she was referred
under the Children Act as a child in need, and the very day that
she died the case was being closed as no further action need (that
was the day she was in the third hospital when her life could
not be saved) I am strongly of the view that nothing more was
known about Victoria Climbieé at the end of the process
than was not in the first referral on the second day she was in
this country. Never once was an assessment of need made; never
once, whether by the hospital, social services or the police service.
What happened to this little girl was shocking in the extreme.
I still find it distressing. It is for that reason I believe passionately
that this is an opportunity that should not be missed, to make
sure that in future what happens at the front door of these services
is actually constantly monitored and is up to standard. If it
is not up to standard it should be identified quickly and action
taken. There are three key questions so far as I am concerned.
First of all, in this day and age, in this country, how could
this have happened? Secondly, how could such bad practice go on
for so long undetected and uncorrected? Thirdly, what can we do
about it? They are the three questions. I hope that this Report
goes a long way to answer those questions.
Julia Drown
12. You talk about six months, when does that
start? It is already two months since the Report was published.
In your mind, when does the six months start?
(Lord Laming) As far as I am concerned, the six months
started the day the Report was published. I have to say that I
took the way in which the Government published the Report to be
immensely encouraging in that the Government has produced a self-audit
document to go to all the key agencies that they have to respond
to by certain timescales, and if their responses are not convincing
I understand that further action could follow. Furthermore, Mr
Millburn said that the Department of Health would be re-writing
the guidance to agencies that produce front line services and
it would be substantially reduced from what it is at the present
time. I welcome all of that. So far as I am concerned we are into
the six months and I said when the Report was launched that I
hoped that before any of these people in key positions think of
going off for their summer holidays, they will have satisfied
themselves that the recommendations that could and should be in
operation are in operation.
13. I do appreciate the difficult balance that
you have in terms of doing more analysis against getting the Report
out as soon as possible to address these extremely important issues.
One of the things that struck the Committee in looking at the
Report though was that there was not a lot of analysis of experience
from other countries. Is there no lesson that could be learned
from any other model or any other approach to this in any other
part of the world that we could actually bring and help us here?
(Lord Laming) That is a very important question. I
thought long and hard about this. Of course, it would be absolutely
foolish to think that there are no lessons to be learned from
other countries. Of course there must be and we could have gone
off on some grand tour I am sure. However, I have actually had
the good fortune to be invited to work in other countries, to
advise in other countries over the last decade. One of the things
I realised is that you can never actually pick up a system from
one country and replicate it in another country. It actually takes
a very large number of years to produce the legislation, get the
values in place and get the system up and running. You will have
gathered, I hope, from my earlier answers that I believe that
there would have been a real danger of deferred action by producing
evidence from other countries. I feel that it would be wholly
unacceptable for these matters to drift on and I did not want
to give anybody either the opportunity or the excuse to allow
that to happen. I believe that basically in this country there
is a sound framework thanks to the legislation that Parliament
has produced and what has flowed from that. What we need to make
sure is that that legislation is implemented in the way that Parliament
has intended. At the present time I think there are too many opportunities
and there was too much evidence in the inquiry of local authorities
and other services actually interpreting the legislation in a
way that I believe that Parliament never intended and I believe
is wholly unacceptable. The test at the end of the day is, can
we make our existing system work? I believe we can make our existing
system work and because of that I thought, "Let's get on
and do it".
Chairman
14. Can I give you an example of where I thought
you may have taken account of experiences in other European countries?
I will raise some specific questions later on about the issue
of chastisement. That will be no surprise to you because you know
my views on this. When David Amess was surprised that 80 children
a year die at the hands of their parents or carers—on average
one a week—it is interesting to look at a not dissimilar
country like Sweden that some years ago outlawed physical punishment
by parents and carers of children. As a consequence of that they
no longer have child deaths. There is no record of child deaths
at the hands of parents or carers compared to our horrendous record
of at least one a week. I wonder if there would be any merit in
actually looking at that experience, not doing a grand tour but
taking account of the fact that where a country has taken a very
significant step that has affected the values in relation to parental
treatment of children, the respect for children which is somewhat
different in certain Scandinavian countries than it is in this
country. Would there have been some merit in examining that model?
(Lord Laming) Maybe so, but I think that one of the
things that I discovered fairly early on—if I needed to
discover it—is that an independent statutory inquiry cannot
be a vehicle for the personal or a professional views of the chairman.
It has to be based on the terms of reference and the evidence
that is produced to the inquiry. If we were going to do an international
comparison it had to be an international comparison that had some
credibility and not just a few favourite topics that I know that
some people are particularly interested in. During the course
of the inquiry, although I lived a monk-like existence in relation
to having no contact with any of the people that might have had
an interest in the inquiry, I did actually allow myself to read
the newspapers and the journals, and what struck me was the number
of expectations that different groups had about what the inquiry
was going to produce and what it was going to address. It would
have been a huge endeavour and largely, for the most part, outside
the terms of reference of the inquiry, to have done that. I thought,
at the end of the day, we either do a proper international comparison
or we do not, but what we cannot do is complain about other people
cherry picking legislation and interpreting it the way they want
to and for us to follow suit. I made a decision and it will be
a matter of judgment as to whether that was the right decision.
Andy Burnham
15. Lord Laming, the comment you made a moment
ago that in your view you did not know any more about Victoria
Climbieé on the day she died then when she was first referred
I think would probably send a shiver down the spine of everybody
and is a damning indictment of some of the structures we have
in this country. Really I would like to bring you on to your analysis
of some of the structural problems that you saw when you did what
I believe will be an immensely valuable analysis of the detail
of what happened. It is fair to say when you have a fairly comprehensive
catalogue of poor practice, gross failure of various parts of
the system, organisation malaise, an absence of leadership and
good management and, reading your recommendations particularly
aimed at social care, the basic nature of those recommendations
is unbelievable. That is really what struck me when I read the
Report and in a sense that is backed up by your belief that 89
of them can be implemented within a six-month timescale suggests
that they are extraordinarily basic. That said, if it is possible,
can I ask you to focus on what is the key intervention in this
malaise, as you have described it? Which thing most needs to happen
urgently to try to turn round some of these dreadful problems?
(Lord Laming) May I just say that it is absolutely
true about the failures of the social service department, but
it was equally true of the police. The most senior person who
came from the Metropolitan Police acknowledged, as he put it,
that in the A to Z of a police investigation this did not reach
B. The issues about the way in which the police carried out their
duties was just as serious, and similarly the health service.
I would not like it to be seen that social services were any greater
failure than the other services. What I think is wrong at the
present time is that there is insufficient managerial accountability
in the system and front line workers are, time and time again,
making decisions about, for example, the use of the Children Act
between Sections 17 and Section 47, a child in need or a child
in need of protection. When they were doing this in order to meet
the needs of children, which is what the Children Act was there
for, to actually recognise that all of these services will meet
a wide range of need and therefore the different sections that
Parliament put into the Act was to create a section which would
best meet the needs of that child and its circumstances, whereas
what they were actually doing was using these sections to restrict
access to services and to limit the availability of services to
people.
16. Because of funding concerns?
(Lord Laming) Let us talk about funding. There are
two issues at least about funding. First of all—as I have
said in the Report and I believe passionately—we had evidence
that some very bad practice is hugely costly. Had Ealing, in my
view, done the job they should have done on the second day that
Victoria was in this country, it is probable that all of the other
agencies would not have needed to be involved. Funding is not
just about more and more money; I have never believed that. When
a local authority has been allocated through the SSA £28
million for services to children and families is spending £14
million and cannot explain why they are spending so much less
than other parts of the country because they have not done an
assessment need, this reflects the low priority given to services
to children and families. I think that too often in recent years
the service has been deflected away from children and families
into the adult agenda and the pressure which is on about getting
people out of hospital, getting people discharged from hospital,
about meeting the needs of adults has led to children's services
having too low a priority. There are some fundamental issues about
resources and funding, but let us not fall into the trap of believing
that more and more money will produce better services. There has
to be an assurance that more and more money actually is about
achieving outcomes for children.
Chairman
17. What you are saying basically is that the
Government's agenda on NHS or social services and the link between
the two is a factor that is perhaps at the heart of some of the
reasons why we have problems of this nature? Or did I misunderstand
what you are saying?
(Lord Laming) No, I think that if you are a front
line worker—and this is not just about social services,
it is about the police, the health service—you are receiving
a whole range of initiatives that come from the centre of Government.
They come from different departments, they come down different
streams to you, and you sometimes do not know what are the priorities.
The police give a very good example. One week it is about street
crime, the next it is about murders in London, the next week it
is about juvenile delinquency or mobile phones being stolen or
whatever it may be. If you are in the front line you have to have
people between the front line workers and the centre. This is
why there has to be a structure which is actually clear about
the priorities. Otherwise what happens is that across 150 local
authorities, 300 primary care trusts, 355 housing departments
they are making decisions which have a direct bearing upon the
well-being of children's families but which do not necessary reflect
what Parliament intended.
18. What you are saying is that there is a very
clear connection between the message from Government on key issues
and the reality—for example social work practice—in
a situation of this nature?
(Lord Laming) Clearly. I recognise that the Government
has a huge responsibility in terms of setting the legislation,
allocating resources, being clear about policies and priorities,
but you cannot run all the services from Whitehall, nor is it
desirable. I am a great believer in local government; I am a great
believer in local agents and local services understanding best
what the local community needs are and how those needs can best
be met not necessarily directly by them but by other services.
But there has to be some kind of coherence in the system. What
you cannot have is a system that we have at the present time where
there is an assumption that because the legislation is good we
can all lay our heads on the pillow at night and think that if
there is a child like Victoria there it will be protected. I do
not believe that is possible.
Julia Drown
19. You hinted there at a criticism of social
services moving in a direction towards perhaps the elderly and
adult services, but is that biased because of the particular authorities
that you have been concentrating on who were spending less, given
most authorities had been spending more, and consistently spending
more, and been investing in children's services? Can that really
be a generalisation across the board?
(Lord Laming) Any generalisation is actually gong
to be wrong in this connection. What we need to know for certain
is what is happening, and there needs to be an assurance that
if people are not delivering good services at a local level that
will be identified early. I think that there were so many telling
points that were made in the seminars. A very successful competent
woman police officer from another part of the country said, for
example, "Whenever I've been involved in a Part 8 review
after the death of a child we have all of us been absolutely astonished
what each of the different agencies knew at the time but no one
of us had a picture. If we had we would have done something about
it to protect the child." What I believe is that at the present
time we cannot go on providing a system which depends upon individual
senior officers being willing to cooperate with each other. Personal
preference ought not to come into this; there should be a requirement.
That is why I believe that it is more than just resources, it
is making sure that resources actually deliver the outcomes that
we want.
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