Victoria: The blame game

The Victoria Climbie Inquiry has sat for a total of three full weeks so far, hearing evidence from more than 100 witnesses. There have been many grim accounts of the events surrounding her lingering death in a shabby north London flat, but one of the most disturbing so far has been a simple tale of everyday office incompetence. Edward Armstrong, a children's social services manager at Brent, told how in the summer of 1999, when Victoria came to their attention, the pile of case files waiting to be inputted was so huge that it physically hid the administration officer from the rest of the social work team.

It was a graphic illustration of how managerial failure quite literally created barriers between the carers and the needy - but it was not the only one. Urgent case referrals simply dropped out of a fax onto a pile on the floor, with nobody to monitor them, he said.

Files went missing so often that a separate "missing files" book had to be created. The situation became so bad that in September 1999 he claimed he was told to close 190 cases - some still active - to persuade a Social Services Inspectorate team that the department was under control.

So concerned was inquiry chairman Lord Laming by this recent evidence that he broke off proceedings to make Brent investigate on-the-spot, fearing that children currently in its care could still be at risk.

The council has dismissed Mr Armstrong's allegations as " unsubstantiated", pointing out that they come from someone who is currently suspended for gross misconduct over his role in the Climbie case. Whether his words are embittered lies or simply the honesty of a condemned man will be for the inquiry to judge.

Also trying to make their minds up are Victoria's parents Berthe and Frances Climbie, who arrived in Britain from the Ivory Coast last month. Since then they have attended virtually every day of the hearing, listening painstakingly as hour after hour of evidence and cross examination is translated into their native French. Whether they feel any the wiser, remains to be seen. The proceedings, with their lawyers, QCs and assorted experts, may have the formality of a judicial inquiry, but on the floor something more of an old-fashioned blame game is being played out.

Social workers have blamed doctors. Doctors blame social workers. Frontline staff point the finger at colleagues in administration. Their managers blame councils for cutting funding in their department. Councils in turn blame the Government. Everybody, in turn, blames the system. Just before the inquiry adjourned for lunch near the weekend, the Climbies had finally had enough. In an unprecedented outburst, they issued a statement saying they were "shocked and disappointed" at the way the various agencies were "blaming each other" rather than taking responsibility for their failings. Their patience may yet be stretched further. There is another six weeks of evidence to go.

All the Climbies can be certain of so far is the poignant account they themselves have given to the inquiry, based largely on the memories of the happy, beaming child who they waved off one day in 1998 to start what should have been a privileged new life in Europe. How Frances's aunt Marie-Therese Kouao, a French national, had arrived out of the blue one day at their home in the Ivory Coast, offering to take one of their six children for a Western education. How the siblings all scrambled at the chance, with Victoria emerging jubilant after Kouao took a shine to her. And how, after nearly two years virtually incommunicado from their daughter, news finally made its way back that Kouao and her boyfriend Carl Manning had been arrested for Victoria's murder.

What they have since learned is that while their child was in England, four councils - Haringey, Brent, Ealing and Enfield - plus the Central and North Middlesex hospitals and the Metropolitan Police, had all been alerted in one way or another to Victoria's plight. The warning signs were many and various - anonymous phone calls, injuries she was treated for in hospital, concerns expressed by babysitters, and the fear she showed of her great aunt - but collectively they were never heeded. In his opening statement, counsel to the inquiry Neil Garnham QC described a "catalogue of failures", saying: "There were at least 12 chances for the agencies charged with duties of child protection to have saved her. All of those chances were missed."

Some of the most culpable witnesses are yet to give evidence, but of those who have so far testified, one word is beginning to stand out - "hindsight". In the knowledge of what happened subsequently, every anonymous phone call, suspicious-looking wound, or fearful glance cast by Victoria at her great aunt could have warranted further investigation. And under the interrogation of Mr Garnham, they frequently sound like they should have done. Nearly all the professionals who have given evidence so far, however, have carefully pointed out that Victoria was just one of dozens or hundreds of cases they had to worry about. Like workers in every other walk of life, they say, they had to prioritise their time.

Instead, the clearest glimpses so far as to why the system failed her have come not from the shortcomings of individuals but of the organisations they worked for. Brent social services does not seem to be the only office where managerial chaos reigned. A near identical picture emerged during the inquiry from an internal police report into the running of Haringey Police Child Protection team, which was twice involved with Victoria. Det Chief Inspector Philip Wheeler found virtually no system for managing or allocating cases, no proper supervision, and a team who turned up for work at whatever hour it suited them. Even worse, this "wholly unacceptable" regime was still in force when he made a return visit several weeks later. As Mr Garnham said: "One has to pinch oneself to remember that the criticisms were being made within six weeks of a child who had been investigated by Haringey Child Protection Team being tortured and murdered by her carers... it seems there is something rotten in the state of Haringey CPT."

In such working environments, the biggest surprise perhaps is that there were not more cases like that of Victoria Climbie. But an equally disturbing factor to emerge so far is the way social services and doctors appear completely at odds over who was finally responsible for deciding whether she was at risk.

Michelle Hines, the senior Brent council social worker who made the fateful decision to lift a child protection order on Victoria after she was admitted to Central Middlesex Hospital with cuts, bruises and burns, has told the inquiry she based her actions largely on the diagnosis of the hospital's consultant paediatrician, Dr Ruby Schwartz. Dr Schwartz had decided that Victoria's injuries were due to scratching from scabies rather than being "non-accidental", and it was not her place to argue with such a respected authority, said Hines. Preventing Victoria being re-united with her aunt would therefore have been wrong and possibly even illegal, she added.

But Dr Schwartz, in her evidence, said she was "incredibly surprised and puzzled" when she learned that social workers had taken her word as final. She said she had classed Victoria as a child "in need" rather than "at risk", but added: "At that point I thought that a full investigation by social services would have been undertaken." As Mr Garnham subsequently remarked, there appears to have been a "terrible danger of social services and doctors each expecting the other to do the investigation, with the result that nobody does".

Where does all this lead so far? Not surprisingly, different parties are reaching different conclusions. Some observers at the inquiry believe it has at least shed some light on life behind-the-scenes in child protection, a field which is by nature secretive because of the sensitive aspects of the work. They say a picture of overall incompetence is gradually building up, made all the worse by the tendency of each party to blame the other.

Some of the councils involved, however, increasingly believe that little is being achieved by picking over the details at leisure. "The inquiry is tending to focus a lot on the minutiae of procedures, such as who sent faxes to whom, when certain letters were written, and so on, but what difference would they have made at the end of the day," one council source told the Evening Standard. "Clearly if everybody had thought this child was labelled to die they would have acted very quickly, but at the time that didn't seem to be the case. Social workers are being crucified for having made the kind of mistakes that everybody else makes in their normal jobs, yet it was not them who killed this child."

As a result, they wonder how much success the inquiry will have in drawing any lasting lessons, despite Lord Laming's avowed intention that it should not simply gather dust on a shelf. The NSPCC believes the case may show the need for a national "children in need board", allowing social workers, police, hospitals and others to integrate more closely along a single line of management and improve communications. But social services directors disagree, saying the lessons of previous inquiries have already been learned. UK child protection procedures are already among the most sophisticated in the world and are subject to constant review. Taken as a whole, Britain's record in child protection is among the best in Europe. Root-and-branch reform of the existing system, they argue, will do nothing but add to the bureaucracy already in place.

Instead, they fear the effect will simply be to make social work posts even more difficult to fill than they are already in London. The inquiry has heard of a "breathtaking" shortage of permanent staff at Brent, where the seven-strong social work team was made up entirely of foreign agency staff on short-term contracts. Some London boroughs currently have vacancy rates of nearly 75 per cent in their childcare field teams, while the national social work average is around 15 per cent.

The inquiry will publish its report - expected to be several hundred pages long - next year. Somewhere, between the hindsight-led approach of its resident QC and the increasingly defensive attitudes of those accused, the truth will lie. Whether the Climbie family will be able to accept it is another matter.