What happened to Victoria?
10. In order to understand the Inquiry conducted
by Lord Laming, it is important to set out briefly Victoria's
story.[8]
Victoria was born near Abidjan in the Ivory Coast on 2 November
1991, the fifth of seven children. According to her parents, she
had a happy and healthy childhood, and did well when she started
at school aged six. In October 1998, Marie-Therese Kouao, the
aunt of Victoria's father visited the family. She had been living
for some time in France and told Francis and Berthe Climbié
that she was prepared to take one of their children back to France
with her and to arrange for their education, and Victoria was
chosen. As Lord Laming commented in his report, entrusting children
to relatives in Europe who can offer opportunities that would
not be available to them in the Ivory Coast was "not uncommon
in Victoria's parents' society."[9]
11. Victoria travelled with Kouao to France, and
stayed there for some five months. Initially Victoria attended
school, but by December 1998 Victoria's absenteeism was causing
concern. When she was in school, Victoria tended to fall asleep
and appeared unwell. By February 1999 the school in Villepinte
was sufficiently concerned to issue a Child at Risk Emergency
Notification. Some time in spring 1999 Kouao informed the school
that she was removing Victoria in order to take her to London
for treatment. Victoria and Kouao arrived in London on 24 April
1999. They travelled on Kouao's passport, which described Victoria
as her daughter named Anna. Anna was the name of another child
that Kouao had previously planned to bring from the Ivory Coast,
and throughout her life with Kouao, Victoria was known as Anna.
12. The day after their arrival in London, Kouao
and Victoria went to Ealing Homeless Persons' Unit seeking accommodation.
They were also in contact with Ealing Social Services. Kouao made
contact with Esther Ackah, a distant relative living in Hanwell,
West London. It was Ms Ackah who was first concerned about Victoria
and who made two anonymous telephone calls to Brent Social Services.
13. From June 1999 Victoria was spending much of
her time with a childminder (Priscilla Cameron) while Kouao went
to work. Victoria would arrive at around 7 am and often not be
collected until 10 pm. Mrs Cameron did not like the way that Kouao
treated and spoke to Victoria who was very subdued when ever Kouao
was present. Kouao had met Manning (driving a bus) in June, and
the following month she and Victoria moved in to his flat in Somerset
Gardens, Tottenham. From this time on, the abuse of Victoria seemed
to increase. Both Ms Ackah and Mrs Cameron had noticed marks on
Victoria, and these became more evident.
14. On 13 July 1999 Kouao asked Mrs Cameron to keep
Victoria permanently because Manning did not want her living with
them. Mrs Cameron was unable to do so, but kept Victoria overnight.
Victoria had many injuries on her face which Kouao claimed were
self-inflicted. The following day Mrs Cameron's adult daughter
took Victoria to the Accident and Emergency department of the
Central Middlesex hospital. The doctor who examined her believed
there was a "strong possibility" that this was a case
of non-accidental injury, and referred Victoria to the paediatric
registrar. The registrar examined Victoria and found a large number
of injuries, at least some of which it was thought could be non-accidental.
Victoria was admitted to the hospital and Brent Social Services
and the police were informed. Another doctor conducted an evening
ward round and concluded that Victoria was suffering from scabies.
15. The next morning Kouao went to the hospital and
took Victoria away. Kouao visited the Camerons to collect Victoria's
things, and Mrs Cameron did not see Victoria again other than
on one occasion when she saw her walking down the road with Kouao.
16. On 24 July 1999, just over a week later, Victoria
was back in hospital. This time she was admitted to the North
Middlesex hospital and had been taken there by Kouao with a scald
to her face, which Kouao claimed Victoria had inflicted on herself
by putting her head under the hot tap. Her burns were so severe
that she was admitted to the paediatric ward and stayed there
for 13 nights.
17. The senior house officer contacted Haringey Social
Services, and a referral was also made by an Enfield social worker
based at the hospital. On 28 July a meeting was held at Haringey's
offices, and Victoria's case was allocated to a social worker
(Lisa Arthurworrey).
18. During her time in hospital Kouao and Manning
visited Victoria whose behaviour changed in their presence; she
appeared afraid of them. Ms Arthurworrey and a police constable
visited Victoria on 6 August 1999 and decided it would be appropriate
for her to be discharged back into Kouao's care. As Lord Laming's
Report observed, "the brief interlude in her life in this
country during which Victoria was safe, happy and well cared for
ended."[10]
She left the North Middlesex hospital on 6 August and returned
to Manning's flat where she was to spend the remaining seven months
of her life.
19. During these months Victoria had little contact
with the outside world, and was seen by professionals on only
four occasions, twice when she was visited by Arthurworrey, and
twice when Kouao took her to Tottenham Social Services claiming
that Victoria had been sexually abused by Manning (although she
later withdrew this allegation). No one from the Tottenham Child
and Family Centre (to which she had been referred by Haringey
Social Services on 5 August 1999) ever visited Victoria.
20. Since moving in with Manning, Victoria had become
at times incontinent of urine, and often wet herself and her bed.
In October 1999, the sofabed on which she had been sleeping was
thrown out of the flat, and Victoria began to spend her nights
in an unheated and unlit bathroom.
21. During Authurworrey's two pre-announced visits
to the flat, little attention was paid to Victoria and Arthurworrey
did not speak to her directly. She believed that the main issue
was the poor housing that the family were in, and that the priority
was to move them to better accommodation. Manning later indicated
that preparations had been made for Authurworrey's planned visits.
The flat had been cleaned and Victoria had been told how to behave
during the visit. Aurthurworrey told Kouao that the council only
accommodated children at risk of serious harm. On 1 November Kouao
telephoned Arthurworrey and made allegations about Manning sexually
abusing Victoria. When questioned alone, Victoria repeated what
Kouao had said virtually word for word, and it was believed that
she had been coached in what to say. Nonetheless, Arthurworrey
told Kouao that Victoria should stay elsewhere while the allegations
were investigated. A person identified by Kouao as a friend (Mrs
Kimbidima) who might help was telephoned. It is not clear if the
friend then changed her mind, but having set off for her home
in a taxi, by the end of the day Victoria and Kouao had both returned
to Manning's flat. The following day Kouao withdrew her allegations
of sexual harm. She was told that Victoria would still have to
live elsewhere until any allegations had been investigated. Kouao
said that they would remain with the Kimbidimas, but in fact they
returned to Manning's flat.
22. This was the last occasion that any of the professionals
involved in Victoria's case saw her until her admission to hospital
the night before she died. Very little is known about the last
four months of Victoria's life.
23. It is believed that Victoria spent most of this
time in the Somerset Gardens flat, although there is some evidence
that she made two brief trips to France with Kouao, where they
stayed with Kouao's son. Back at Somerset Gardens Victoria continued
to be forced to sleep in the bath, and was tied up inside a black
plastic sack. As a result Victoria spent long periods lying in
her own urine and faeces. The sack ceased to be used when Victoria's
skin condition became so damaged that Manning said they were concerned
that "undue questions" would be asked. While no longer
being kept in a bag, Victoria spent most of her days and nights
confined in the bathroom.
24. By the beginning of 2000 Victoria was also being
given her food on a piece of plastic in the bathroom. Her hands
were tied with masking tape and she would be pushed towards the
food to eat it like a dog.
25. Victoria was also beaten regularly by Manning
and Kouao. Manning later reported that Kouao struck Victoria on
a daily basis, using various implements including a shoe, a coat
hanger, a wooden spoon and a hammer. Victoria's blood was found
on the walls of the flat, on Manning's football boots and trainers.
He also admitted to beating Victoria with a bicycle chain.
26. By 19 February 2000 Victoria had become very
ill. Kouao took Victoria with her to the Universal Church of the
Kingdom of God on Seven Sisters Road. Kouao spoke to the minister
(Pastor Lima) and told him of the problems she was having with
Victoria, particularly with her incontinence. Pastor Lima expressed
the view that Victoria was possessed by an evil spirit and advised
Kouao to bring Victoria back to the church a week later. During
the week Kouao telephoned the Pastor and reported that Victoria's
behaviour and incontinence was improving. However, later in the
week Kouao returned to the church with Victoria where Pastor Lima
advised them to go to hospital and called a minicab.
27. The minicab driver took Victoria and Kouao to
the nearby Tottenham Ambulance Station. Victoria was then taken
by ambulance to North Middlesex hospital and admitted to casualty.
Her temperature on arrival was 27 degrees Celsius (compared with
a normal temperature of 36-37C), and attempts to warm her were
unsuccessful. The paediatric consultant believed that Victoria
needed specialist care, and a place was found for her at St Mary's
Hospital Paddington. Victoria was transferred to St Mary's with
severe hypothermia and multi-system failure. Her respiratory,
cardiac and renal systems all began to shut down and Victoria
went into cardiac arrest. Attempts at cardio-pulmonary resuscitation
failed and Victoria was declared dead at 3.15 pm on 25 February
2000. Ironically, this was the very day that Haringey Social Services
formally closed her case.[11]
28. A post-mortem was conducted the following day.
The cause of death was found to be hypothermia caused by malnourishment,
a damp environment and restricted movement. The pathologist found
128 separate injuries on Victoria's body caused by both sharp
and blunt instruments. No part of her body was spared injury.
Marks on her wrists and ankles indicated that Victoria had been
tied up. The pathologist reported that it was "the worst
case of deliberate harm to a child he had ever seen."[12]
29. Later on 25 February 2000 Kouao was arrested
on suspicion of neglect, Manning was arrested the following day.
Both were subsequently charged with Victoria's murder. They were
convicted on 12 January 2001 and are serving sentences of life
imprisonment.[13]
30. Victoria's story highlights the system going
badly wrong at every step. Lord Laming told us:
Had this tragedy of Victoria Climbié 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 ... However, when you get the whole system
engaged, when the second day this child was in the 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 was needed, 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 Climbié 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.[14]
31. It is the reasons for this systematic failure
that must be understood and addressed if further tragedies of
this nature are to be avoided. It is to these issues that we now
turn.
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