House of Commons - Health

Select Committee on Health Sixth Report

2. What went wrong and why

32. The previous chapter has provided a factual account of Victoria's final months spent in this country. While this describes the multiple opportunities when someone might have intervened and done something to help Victoria, it fails to indicate why this did not occur. Lord Laming told us that there were three key questions as far as he was 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? And thirdly, what can we do about it?[15]

33. In seeking to understand what had gone wrong in this case, Lord Laming observed that the inquiry could have lasted for many years, and it turned out to be much larger than anticipated. At the outset it was believed that because Victoria had spent a relatively short time in the country, the Inquiry would need to see in the region of 30 witnesses. In the event, 277 witness statements were taken.[16] Lord Laming had to find a balance between pursuing many issues in great detail, and getting a report produced as soon as possible in order to address issues of fundamental importance.

Gross failures of the system

34. The Inquiry Report identified an absence of basic good practice. There were at least 12 key occasions when the relevant services had opportunities successfully to intervene to help Victoria, but had failed to do so. The Report states that not one of these interventions would have required great skill or made heavy demands on staff:

Sometimes it needed nothing more than a manager doing their job by asking pertinent questions or taking the trouble to look in a case file. There can be no excuse for such sloppy and unprofessional performance.[17]

35. As Lord Laming commented, not one of the agencies empowered by Parliament to protect children in positions such as Victoria's emerged from the Inquiry with much credit.[18] What happened to Victoria, and her ultimate death, resulted from an inexcusable "gross failure of the system."[19] Lord Laming's Report expressed his amazement that nobody in the agencies "had the presence of mind to follow what are relatively straightforward procedures on how to respond to a child about whom there is concern of deliberate harm."[20] We share Lord Laming's amazement that the system failed so comprehensively.

36. The Inquiry Report highlighted "widespread organisational malaise" as the principal reason for the lack of protection afforded to Victoria. In relation to the Health Service it was apparent that the basic discipline of medical evaluation—history taking, physical examination, differential diagnosis, note keeping, handover of care and monitoring of outcome—was simply not followed. Lord Laming speculated that medical staff felt especially uncomfortable about investigating evidence of deliberate harm to children. Their training in following the normal systematic approach to the diagnosis of illness appeared to have been entirely ignored in Victoria's case. When the possibility of non-accidental injury was raised by one doctor, it was not picked up by others because of poor or absent handover of responsibility of care, and then obscured by another diagnosis which was not confirmed. The organisational systems were not in place to ensure continuity of care or adequate consultant supervision. Lord Laming expressed this as follows:

We cannot operate a system where the safety and well being of children depends upon the personal inclinations or ability or interests of individual staff. It is the organisations which must accept accountability.[21]

The paediatric units throughout the country should be instructed to review their arrangements for ensuring continuity of care, supervision of junior medical staff and medical audit.

37. Who should be held responsible for these failures? Lord Laming was clear that it is not the 'hapless' and sometimes inexperienced front-line staff to whom he directs most criticism, but to those in positions of management, including hospital consultants. He told us:

I think that the performance of people in leadership positions should be judged on how well services are delivered at the front door. Too often in the Inquiry people justify their positions around bureaucratic activities rather than around outcomes for children. Frankly, I would be the very last person to say that good administration is not essential to good practice. Good administration—and we did not see a lot of it, I have to say—is a means to an end. I cannot imagine in any other walk of life if a senior manager was in charge of an organisation and that organisation was going down the pan—to put it crudely—in terms of sales and performance that someone would say 'My role is entirely strategic, do not hold me to account for what happens in the organisation.' … People who occupy senior positions have to stand or fall by what service is delivered at the front door.[22]

38. The Inquiry Report highlighted the apparent failure of those in senior positions to understand, or accept, that they were responsible for the quality, efficiency and effectiveness of local services. Indeed, Lord Laming pointed to the 'yawning gap' in the differing perceptions of the organisation held by front line staff and senior managers. Lord Laming was unequivocal that the failure was the fault of managers whose job it should have been to understand what was happening at their 'front door.' As the Report pointed out, some of those in the most senior positions used the defence "no one ever told me" to distance themselves from responsibility, and to argue that there was nothing they could have done.[23] This was not a view shared by Lord Laming, nor is it our view.

39. Lord Laming went even further in evidence to us, telling us forcefully that, in his view, accountability of managers was paramount, and that the front line staff were generally doing their utmost:

I do not believe that any one of the junior staff or the front line staff that came to the Inquiry were anything other than distressed at what happened to Victoria. I do not believe that any of them were not well motivated. I do not believe that any of them did not set out to do a reasonable job of work. The question is why are these well intentioned people put in a situation where they felt defeated by the task that they had?[24]

40. In addition to the fundamental problems of a lack of accountability and managerial control, it was also apparent in the course of the Inquiry that other failings existed in all aspects of practice. As with many previous inquiries into child protection failures, it was clear that the quality of information exchange was often poor, systems were crude and information failed to be passed between hospitals in close proximity to each other. As the Report commented, "information systems that depend on the random passing of slips of paper have no place in modern services."[25]

41. The question of adequate training and supervision for staff working in all the relevant agencies was also an issue identified in the Inquiry. In Haringey, for example, it was observed that the provision of supervision may have looked good on paper "but in practice it was woefully inadequate for many of the front line staff." Nowhere was this more evident than in the fact that in the final weeks of Victoria's life a social worker called several times at the flat where she had been living. There was no reply to her knocks and the social worker assumed, quite wrongly, that Victoria and Kouao had moved away, and took no further action. As the Laming Report commented, it was entirely possible that at the time "Victoria was in fact lying just a few yards away, in the prison of the bath, desperately hoping someone might find her and come to her rescue before her life ebbed away."[26]

Adequacy of resources

42. In commenting on the adequacy or otherwise of resources, Lord Laming's analysis was more sophisticated than that of many commentators who have concluded that the issue is simply one of putting more money in the system. He argued to us, as he had also stated in his Report, that bad practice was extremely costly, and "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."[27] He also pointed out that Ealing, Brent and Haringey were, at the time of Victoria's case, all spending significantly below their Standard Spending Assessment (SSA) on services for children. This was in sharp contrast with the national picture, where most local authorities were overspending their SSA on services for children and families.[28]

43. An obvious question to ask was why authorities would underspend their SSA for children and families? The apparent low priority given to such services, Lord Laming told us, appeared to be a reflection of the pressures and demands from central policy:

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.[29]

44. This raises some very important issues. We urge the Department of Health to examine whether current health service priorities have had deleterious effects on local priorities for children and families.

45. Lord Laming cautioned against "believing that more and more money will produce better services." In his view, there had to be "an assurance that more and more money actually is about achieving outcomes for children."[30] In their response to the Laming Inquiry the Association of Directors of Social Services (ADSS) supported unreservedly the core principles of the Report, but challenged whether the recommendations could be delivered within existing resources, and argued the case for a thorough review of funding for social care similar to that undertaken for the NHS by Derek Wanless.[31] Indeed, Mr Wanless himself has called for such a review. While Lord Laming appeared to have limited patience with the argument that social care was under-resourced, he acknowledged that such a contention might carry more weight "if there was some intellectual rigour behind it that actually produced evidence to support such claims."[32]

46. We agree with the arguments made by the ADSS, and in the past by the King's Fund, that there should be an independent review of funding for social care, along the lines of the Wanless review of the NHS. We recommend that the Government should commission an urgent review of the factors influencing demand for social care for children and adults, and consider the adequacy of resources currently allocated.

Failure fully to implement the Children Act

47. Lord Laming told us that he continued to believe that the Children Act 1989 was "basically sound legislation". His recommendations do not argue for a major new legislative framework. However, he did not believe that the Act was being implemented in the way that had been envisaged for it, and, in his view, there was "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."

48. In the absence of adequate managerial accountability, front line workers were obliged to make crucial strategic decisions, for example about the use of the Children Act, and between using sections 17 and 47 (relating respectively to a child in need, and a child in need of protection). The sections of the Act had been developed with the intention of recognising the different needs of children. How the sections were being applied on the ground, Lord Laming told us, was quite different. Far from employing the section of the Act that would best meet the needs of the particular child and their circumstances, "what they were actually doing was using these sections to restrict access to services and to limit the availability of services to people."[33] The Children Act, Lord Laming argued to us, "should be about promoting the well-being of children, not about putting labels around people's neck." He went on to suggest that front line workers were being forced into making decisions that should properly have rested with management and policy decisions. This raised major questions about the role of public services and the basic principles that should underpin them, as Lord Laming observed:

We heard evidence that made me think that we need to stand back and say that we need to discover the basic principle that the public services are there to serve the public, not just some of the public and not just some people who can get through eligibility criteria, who can go over hurdles or who are sufficiently persistent. Therefore services must be more accessible and they must be more in tune with their local communities.[34]

49. If, as Lord Laming believes, the Victoria Climbié case was not unique, but highlighted widespread and major deficiencies in the implementation of the Children Act, this raises issues that Government should address. We believe that the Children Act 1989 remains essentially sound legislation. However, we are concerned that the provisions of the Act which sought to ensure an appropriate response to the differing needs of children are being applied inappropriately, used as a means of rationing access to services, and have led to section 17 cases being regarded as having low priority. The Laming Inquiry recommended that consideration should be given to unifying the Working Together guidance and the National Assessment Framework guidance into a single document, setting out clearly how the sections of the Act should be applied, and giving clear direction on action to be taken under sections 17 and 47.[35] We strongly support this recommendation.

Moving Forward

50. The Inquiry into Victoria Climbié's case was charged not only with investigating what happened to Victoria, but also with making recommendations as to how such an event may, as far as possible, be avoided in the future. We turn now to consider those recommendations.

15 Q11 Back

16 Q10 Back

17 The Victoria Climbié Inquiry, Para 1.17 Back

18 The Victoria Climbié Inquiry, Para 1.18 Back

19 Ibid Back

20 The Victoria Climbié Inquiry, Para 1.1 Back

21 Q33 Back

22 Q22 Back

23 The Victoria Climbié Inquiry, Para 1.26 Back

24 Q26 Back