victoria climbié case review summary

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The Victoria Climbie inquiry : summary and recommendations

This report contains a summary and recommendations from the Public Inquiry into the death of Victoria Climbie.

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The Victoria Climbie Inquiry: report of an inquiry by Lord Laming

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Victoria Climbie inquiry report - key findings

Published on: 9 October 2003

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Child protection—lessons from Victoria Climbié

In his report on the torture, starvation, and eventual murder of Victoria Climbié, Lord Laming noted that any case of deliberate harm to a child is a serious and potentially fatal condition that deserves the same quality of diagnosis and treatment as a brain tumour or heart disease. 1 His report includes a long list of recommendations. He stresses the importance of accurate written records, discharge plans, and better information systems. His support for a “commissioner for children” is welcome. 2 The proposed new national and local managerial structures should improve supervision, coordination, and accountability. But the key question is not who will be accountable for the next child abuse tragedy 3 but how much the better reporting arrangements will contribute to preventing one.

The answer is, probably not a lot, unless there is also professional and managerial commitment to other, and arguably more important, changes. Prevention depends on collaboration, as emphasised in the publication Working Together from the Department of Health. 3 But it is not just organisations, committees, and boards that must work together. Children like Victoria die when individual professionals do not work together. Often the reasons lie in failures of systems rather than individual shortcomings. Within hospitals, changed working practices threaten continuity of care in clinical teams. Different geographical boundaries between agencies, high staff turnover, workload pressures, and indifferent managerial support make it increasingly difficult for health professionals, social workers, and police officers to train together and manage cases together. This in turn prevents the development of the mutual trust and respect that are gained only through regular collaboration and an understanding of each other's perspectives and organisational cultures.

Lord Laming rightly emphasised the importance of better education, training, and quality monitoring. This is no small task. All general practitioners treat children and have a duty to be aware of the many different manifestations of child abuse and to respond by seeking advice. A higher level of knowledge and competence is expected of paediatricians, whether generalists or specialists—they have a duty of care to any child in whom abuse is being suspected, unless or until they have formally transferred responsibility to someone else. The syllabus for all paediatric trainees must include patterns of abuse, legal and ethical issues, and an understanding of social and cultural factors and of the motivation for abuse. 4 Clinical training should cover multiprofessional teamwork, interviewing and consultation skills with children and parents (particularly those who are hostile, aggressive, violent, or mentally ill), physical examination, preparing reports, and giving evidence.

Specialised help must be available for the investigation of suspected sexual abuse and for advice in unusual, complex 5 or contentious cases. 6 Doctors who take on these tasks need additional opportunities for training and professional development and a means of accreditation that confirms their expertise to clinical and forensic colleagues and to the judiciary.

As with any difficult clinical situation, consultation with colleagues is important. Local support should be available from the designated and named doctor and nurse, whose roles are defined in Department of Health guidance. Every chief executive must ensure that these individuals have enough time and resources to do their jobs properly. This must include opportunities to form continuing education and support networks with others in similar posts. A process of audit should be in place in each department of the hospital to monitor adherence to local and national statements of good practice. 7

The designated and named professionals would have a leading role in the local implementation of Lord Laming's most ambitious proposal—for regular revalidation in child protection of every consultant paediatrician and general practitioner. This might best be achieved by a standardised package and process, which would be equally relevant for trainees. The model could be based on that already established for resuscitation training, as in the advanced paediatric life support course. This is taught largely by consultants, and in doing so they also maintain their own expertise. The cost of developing and maintaining a similar system for child protection will be substantial—although probably less that that of a public inquiry into a child's death.

Lord Laming heard evidence that child protection is an unpopular specialty of paediatrics. He chose not to address the reasons in detail. There are many, 8 but one issue that increasingly inhibits high quality child protection work is the fear of complaints and litigation. No one condones poor clinical practice, but some complaints are malicious and are intended to obstruct social work and police investigations, and some arise from orchestrated campaigns. 9 The NHS complaints system was not designed to deal with such situations.

Amid the justifiable horror at the death of Victoria Climbié and the focus on violent physical abuse, we must not neglect the opportunities for prevention. 10 This too is the responsibility of all who work with children, 11 but in the health service it particularly falls on primary care staff, including midwives, health visitors, school nurses, 12 and on those working with mentally ill adults and drug misusers. These teams naturally focus on the needs of their adult patients and are at risk of forgetting the child or children at home.

Competing interests: The College is seeking funds to extend a training scheme in child protection in collaboration with NSPCC and Johnson and Johnson Pediatric Institute.

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Q&A: Victoria Climbié inquiry

What prompted the inquiry?

The murder of eight-year-old Victoria Climbie in February 2000 exposed serious failings by the child protection services and staff responsible for her welfare. The girl, who came to Europe from west Africa in the hope of a better life, died of hypothermia after months of torture and neglect inflicted by her sadistic great aunt, Marie Therese Kouao, and the woman's boyfriend, Carl Manning. Kouao struck Victoria on a daily basis with a shoe, a coat hanger and a wooden spoon and hit her toes with a hammer. Manning beat her with a bicycle chain. She spent her last days in an unheated bathroom, tied up in a bin bag, lying in her own urine and excrement. Her abusers were jailed for life in November 2000. During the trial, police, health and social services involved in the case were described as "blindingly incompetent". In January 2001, the health secretary, Alan Milburn, ordered a statutory public inquiry into her death headed by former chief inspector of social services, Lord Herbert Laming.

Why was Victoria's death so significant?

Her suffering exposed flaws in all of the main services involved in child protection. The girl was known to four London boroughs' social services departments - Haringey, Ealing, Brent and Enfield - three housing departments, two hospitals - Central Middlesex and North Middlesex - two Metropolitan police child protection teams, and a specialist centre run by the National Society for the Prevention of Cruelty to Children. The tragedy pointed to a complete breakdown in the multi-agency approach to child protection established after the murder of seven-year-old Maria Colwell in 1973. The case also highlighted the plight of the thousands of children who enter the UK every year under private fostering arrangements - most of whom, like Victoria, come from west Africa. They slip through the net because their carers are not required to register as foster parents, which makes it impossible to keep track of them.

What is the scope of the public inquiry?

It was the first "tripartate" inquiry into child abuse, investigating the role of social services, the NHS and the police, under the Children's Act, NHS Act and Police Act. The inquiry was charged with establishing the circumstances leading to and surrounding Victoria's death; how the police, health and social services complied with their official responsibilities; and to make recommendations to the government as how to prevent such a tragedy from happening again. The first phase of the inquiry focused on Victoria's case, but the second part considered its implications for the whole of the child protection system.

What failures did the investigation uncover?

The inquiry found that care workers missed at least 12 chances to save Victoria. Despite their contact with the girl, staff knew no more about her when she died than when they first saw her. Lord Laming said it was lamentable that "nothing more than basic good practice" would have saved her but "this never happened". All the services involved were under-funded and short-staffed, while child protection policies and guidelines were up to a decade out of date. The report highlights the "bad practice" of frontline staff such as Victoria's social worker, Lisa Arthurworrey, who never spoke to the girl apart from in the presence of her abusers. But the most scathing criticism is reserved for senior managers, such as the former chief executive of Haringey council, Gurbux Singh, who rejected any accountability for the tragedy. This poor leadership contributed to "widespread malaise" in the police, health and local authority services responsible for Victoria's welfare.

What are Lord Laming's main recommendations?

The main reforms proposed by his report are aimed at holding those in senior positions, from the government down to local services, to account for any failure to protect vulnerable children. A cabinet minister should chair a children and families board to consider the impact of all government policies on children and families. This should be supported by a national agency for children and families, possibly led by a children's commissioner. This would advise the board on the impact of proposed policies; scrutinise legislation and guidance; advise on implementing the UN convention on child rights; ensure that policy and legislation are implemented at local level; and review serious cases of abuse. Every local authority social services department should establish a committee for children and families, with members from education, housing and social services, the police authority, and the local NHS. This committee should oversee the work of a management board for services to children and families. The board should be chaired by the council chief executive and include senior officers from the police, social services, NHS, education, housing, and probation. These local arrangements would be overseen by national inspectorates. The local committees would report through regional government offices to the national agency. The ministerial board would report annually to parliament.

What else has been proposed?

A national database should keep a record of every contact every child under 16 has with the police, health and local authority services to prevent them getting lost in the system. Doctors who suspect children are being abused should take histories from them without their parents' consent. Councils should set up 24-hour helplines for the public to report concerns about children's safety.

How soon will these reforms be implemented?

The government is not expected to reveal how many of Lord Laming's recommendations it intends to implement until it publishes its green paper on children at risk later this spring. If accepted by ministers, some of the 108 proposals - such as the national agency and children's database - would require legislation and could take three years to put into effect. But 82 of the ideas could be acted on within six months.

What is the likely impact of the inquiry?

Until it becomes clear how many of its recommendations will be accepted by ministers, that is unclear. There have been at least 70 previous public inquiries into severe child abuse in Britain, 67 of which have been in England. The vast majority of these cases were startlingly similar to Victoria's concerning children killed after months of torture and neglect. The first of the public inquiries in 1945, which followed the death of 13-year-old Denis O'Neill, made a significant impact on child protection. It led to a new Children Act and the creation of local children's committees. The Maria Colwell report in 1974 also led to significant reform creating local committees to coordinate child protection, which would be scrapped under Lord Laming's plans. Many of the inquiries have made the same recommendations about poor communication and coordination, bad practice and inadequate supervision, but these were often shelved or ignored due to a lack of political will by central and local government, a lack of resources and some professionals' resistance to change. Worryingly, the Laming report fails to address the issues of inadequate funding and staff shortages, which threaten to scupper any reform.

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The Victoria Climbie enquiry: summary and recommendations

This summary report contains three sections from the main report: sections one, three and eighteen. Section one outlines an introduction chronicling the events, the extent of injuries, what went wrong, and the future of the child support system; section three details Victoria's story, her abusers and the interactions with social services staff; section eighteen comprises a summary of recommendations. For ease of reference recommendations are expressed in terms of the Local Authorities Personal Services Act 1970.

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Serious Case Reviews and Inquiry Reports: Investigating the Emotional, Sensory and Relational Dimensions of Child Protection

• First Online: 12 January 2018

Cite this chapter

• Sharon Pinkney 2  

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Within this chapter, three child abuse inquiry and Serious Case Review reports are explored to understand the contemporary landscape of Children’s Services and the ongoing challenges involved in protecting children and young people from harm. These are Victoria Climbié (Laming. The Victoria Climbié inquiry: report of an inquiry. Department of Health. HMSO, London, 2003 ), Hamza Khan (BSCB. Serious case review, Hamzah Khan. The overview report, November 2013) and the Jay Report (Independent inquiry into child sexual exploitation in Rotherham, 1997–2013. Rotherham MBC, Rotherham, 2014) on child sexual exploitation. They are reviewed within the context of the critical interdisciplinary perspective developed in the earlier chapters. The aim is to understand how the sensory, emotional and relational perspectives provide a further context for understanding these cases. The chapter examines multi-professional teamworking in the UK (Multi-Agency Safeguarding Hubs) and internationally (Barnahus) developed to ensure the services are child centred.

• Serious Case Reviews
• Children’s Services
• Child protection
• Victoria Climbié
• The Jay Report
• Child sexual exploitation
• Multi-professional teamworking

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Pinkney, S. (2018). Serious Case Reviews and Inquiry Reports: Investigating the Emotional, Sensory and Relational Dimensions of Child Protection. In: New Directions in Children’s Welfare. Palgrave Macmillan, London. https://doi.org/10.1057/978-1-137-54539-8_5

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History of child protection in the UK

Legislation to prosecute people accused of child cruelty has been in force since the 1880s. Over time a range of factors, including some high profile child abuse deaths and subsequent inquiries, have contributed to the development of the child protection system we have in the UK today.

Now, statutory child protection guidance across the UK is regularly reviewed and updated in consultation with stakeholders.

On this page, you'll find a timeline of the key events that have taken place since 1945, leading to the development of today’s child protection system. We have provided links to legislation and publications where possible.

> Find out more about the development of the child protection system in the UK by searching the NSPCC library catalogue

1945 – The first child abuse inquiry

The first formal child death inquiry took place in England in 1945 into the death of Dennis O'Neill, who was killed at the age of 12 by his foster father.

> Read more about the inquiry report on our library catalogue

1946 – Curtis committee and Clyde committee

The Care of Children Committee, led by Dame Myra Curtis, investigated and made recommendations about how care was provided for children who weren’t able to live with their own parents or relatives in England and Wales .

James L. Clyde led the Committee on Homeless Children in Scotland , which had a similar remit.

The recommendations of both committees contributed to the development of the 1948 Children Act.

1948 – Children Act

The Children Act 1948 (no longer available online) set out new support measures for children across the UK. Under the Act, local authorities had a duty to provide care for any child whose parents were unable to care for them, if this was in the child’s best interests.

1973 – Reforms made to the child protection system

At the age of 7, Maria Colwell was killed by her step-father after being returned home from foster care. The public inquiry that followed her death found that Maria had been failed by the child protection system.

The need to improve the system contributed to the development of stronger measures to enable professionals working with children to recognise and respond to child abuse and neglect, including the Children Act 1975.

> See our reading list on the reforms made to the child protection system following the death of Maria Colwell

1975 – Children Act

The Children Act 1975 built on the 1945 Act and highlighted the importance of children’s welfare. It also established the role of an independent social worker who would ensure the best interests of the child during court proceedings.

1984 – The transformation of child protection services

Further changes to child protection legislation were prompted partly by the inquiries into more child deaths, including 4-year-old Jasmine Beckford who was killed by her step-father after being returned home from care.

1988 – Working together guidance first published

The first edition of Working Together consolidated guidance and recommendations on procedures for the care and protection of abused children and children at risk in England and Wales . Working together: a guide to arrangements for inter-agency co-operation for the protection of children from abuse (DHSS and Welsh Office, 1988) 1 also introduced serious case reviews (SCRs), referred to at the time as case reviews, for the first time.

> Read the guidance via our library catalogue

1989 – Children Act for England and Wales

The Children Act 1989 established the legislative framework for the current child protection system in England and Wales . It sets out the paramountcy principle – that the welfare of the child should be the court’s main consideration.

1990 – United Nations Convention on the Rights of the Child

The UK signed the United Nations Convention on the Rights of the Child (UNCRC), which sets out the rights of every child in the world to survive, grow, participate and fulfil their potential.

1991 – Working together guidance updated in response to the Children Act

In 1991, Working together under the Children Act 1989: a guide to arrangements for inter-agency co-operation for the protection of children from abuse was published (Home Office and Department of Health, 1991). 2 It included the requirements of the Children Act 1989 as well as compiling previous guidance on child protection and best practice.

Guidance had to be followed by local authority social services departments unless local circumstances indicated exceptional reasons which justified a change.

1995 – Children Order and Act for Northern Ireland and Scotland

The Children (Northern Ireland) Order 1995 and the Children (Scotland) Act 1995 established the legislative framework for the current child protection systems in Northern Ireland and Scotland .

1997 – Criminal records checks

Part V of the Police Act 1997 established a centralised system of criminal records checks across the UK.

1999 – Devolution and major revision of Working together guidance

Since 1999 the process of devolution has seen power and responsibility transferred from the Houses of Parliament in Westminster to national governments in Northern Ireland , Scotland and Wales .

1999 also saw a revised version of the Working together guidance published for England. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF) (Department of Health, 1999) 3 included guidance on working together to support children and families, lessons from research and experience, and definitions of abuse.

2000 – Major changes in child protection policies

The death of 8-year-old Victoria Climbié, following abuse and neglect by her great-aunt and great-aunt’s boyfriend, led to Lord Laming’s report (Laming, 2003). 4  This report contributed to sweeping changes to the way children's services were structured in England and Wales .

> Read Lord Laming’s report via our library catalogue

Three-year-old Kennedy McFarlane was killed by her mother’s boyfriend when he hit her, leading her to crash into the leg of a bed. Her death led to the Scottish education minister, Jack McConnell, announcing a review of child protection in Scotland (Scottish Executive, 2002). 5

> Read the Scottish Executive's report of the Child Protection Audit and Review via our library catalogue

2001 – First Children’s Commissioner

The Children's Commissioner for Wales Act 2001 created the first children’s commissioner post in the UK.

2002 – Reforms to child protection legislation

Holly Wells and Jessica Chapman, both aged 10, were killed by Ian Huntley, their school caretaker. He had previously been investigated by police for crimes including burglary, indecent assault and rape.

Following his conviction, an inquiry led by Michael Bichard recommended the development of a system where people are appropriately vetted before working with children. This led to the strengthening of legislation across the UK to protect children from adults who pose a risk to them, including the Safeguarding Vulnerable Groups Act 2006 in England , Northern Ireland and Wales , and the Safeguarding Vulnerable Groups (Northern Ireland) Order and Protection of Vulnerable Groups (Scotland) Act . 

> See our reading list about the reforms to child protection legislation following the deaths of Jessica Chapman and Holly Wells

2003 – National guidance and Children’s Commissioner in Northern Ireland, Children and Young People’s Commissioner for Scotland

The statutory guidance Cooperating to safeguard children and young people was published in Northern Ireland , to set out requirements for safeguarding children in the statutory, private, independent, community, voluntary and faith sectors (Department of Health, Social Services and Public Safety, 2002). 6

Northern Ireland created the post of Commissioner for Children and Young People (NICCY).

The Commissioner for Children and Young People (Scotland) Act 2003 established the role of Children and Young People’s Commissioner in Scotland .

2004 – Children Act, UNCRC

The Children Act 2004 , informed by Lord Laming’s report, established a Children’s Commissioner in England (the last of the UK nations to appoint one); created Local Safeguarding Children's Boards (LSCBs) in England and Wales ; and placed a duty on local authorities in England to appoint a director of children’s services and an elected lead member for children’s services, who is ultimately accountable for the delivery of services.

The Welsh Government formally adopted the United Nations Convention on the Rights of the Child (UNCRC) (Welsh Government, 2019). 7

2006 – Working together update, Safeguarding Vulnerable Groups Act and GIRFEC

The Safeguarding Vulnerable Groups Act 2006 was passed in England , Northern Ireland and Wales following the recommendations of the inquiry into the events surrounding the deaths of Holly Wells and Jessica Chapman in 2002.

Scotland’s Minister for Children published a review of the Children’s Hearing System, entitled Getting it right for every child (GIRFEC) (PDF) , highlighting a dramatic increase in identified children with multiple needs (Creegan, C., Henderson, and King, 2006). 8

Working together to safeguard children (PDF) , the statutory guidance for child protection in England was revised to incorporate changes in safeguarding policy and practice since 1999. The guidance included 12 chapters, with chapters 1 to 8 being statutory guidance for child protection in England (Department for Education and Skills, 2006). 9

> Read Getting it right for every child (2006) via our library catalogue

2007 – Protection of Vulnerable Groups in Northern Ireland and Scotland

The Protection of Vulnerable Groups (Scotland) Act 2007 and Protection of Safeguarding Vulnerable Groups (Northern Ireland) Order 2007 were passed.

2008 –The case of Peter Connelly (Baby P)

The death of one-year-old Peter Connelly (Baby P) following abuse and neglect by his mother, her boyfriend and her boyfriend’s brother, led to further reviews of social service care in England by Lord Laming, with the House of Commons debating the case.

Lord Laming’s The protection of children in England: a progress report (PDF) made 58 recommendations for child protection reforms (Laming, 2009). 10

> See our reading list to read more about the lessons learnt following the death of Peter Connelly

2010 – Working together revised and the publishing of serious case reviews

Minister for Children and Families, Tim Loughton, announced that Local Safeguarding Boards in England should publish the overview report and executive summary of all case reviews initiated on or after 10 June 2010.

The Secretary of State for Education, Michael Gove, also commissioned Professor Eileen Munro to conduct an independent review of child protection in England .

Working together to safeguard children (PDF) for England (Department for Children, Schools and Families, 2010) 11 was also revised following the publication of Lord Laming’s report (Laming, 2009).

2011 – Munro review in England, Safeguarding Boards and UNOCINI in Northern Ireland, and children's rights in Wales

Professor Munro’s report A child-centred system (PDF) sets out recommendations to “help to reform the child protection system from being over-bureaucratised and concerned with compliance to one that keeps a focus on children, checking whether they are being effectively helped, and adapting when problems are identified” (Munro, and DfE, 2011). 12 This led to a review of the statutory child protection guidance in England .

The Safeguarding Board Act (Northern Ireland) 2011 set out the law for the creation of a new regional Safeguarding Board for Northern Ireland and the establishment of five Safeguarding Panels.

The Understanding the needs of children in Northern Ireland (UNOCINI) (PDF) guidance was published to enable practitioners working with children to better meet the needs of children and their families (Department of Health, 2011). 13

To ensure children’s rights are included in all policy making in Wales , the Welsh Government made the United Nations Convention on the Rights of the Child part of its domestic law through the Rights of Children and Young Persons (Wales) Measure .

2012 – Operation Yewtree, Protection of Freedoms Act and Historical Institutional Abuse (HIA) Inquiry

Operation Yewtree was set up by the Metropolitan Police Service to investigate sexual abuse allegations against Jimmy Savile and others.

> Read the Giving victims a voice report via our library catalogue

The Protection of Freedoms Act 2012 in England and Wales set out the requirements for vetting and barring checks for adults who are working or volunteering with children, whilst being supervised by someone else.

The Northern Ireland Executive agreed the terms of reference for its Historical Institutional Abuse Inquiry (the HIA Inquiry) and appointed Sir Anthony Hart as chair.

2013 – Review of sexual exploitation in Rochdale and updates to Working together guidance in England 

The independent review into child sexual exploitation (CSE) in Rochdale examined the council’s response to issues around child sexual exploitation (CSE), after 47 girls were identified as victims of CSE (Klonowski, 2013). 14

A new version of Working together to safeguard children (PDF) was published in England , informed by the Munro review (DfE, 2013). 15

2014 – National legislation and guidance in Scotland and Wales and Jay report

The Social Services and Well-being (Wales) Act 2014 provided Wales with its own legislative framework for social services for children and adults.

Section 130 of the Act requires “relevant partners” of a local authority to inform the local authority if they have reasonable cause to suspect a child is at risk of experiencing abuse, neglect or other types of harm.

Under Section 145 it gives powers to Welsh Ministers to issue codes of practice providing guidance, objectives and requirements on local authorities’ provision of social services.

The Children and Young People (Scotland) Act 2014 aimed to strengthen the rights of children and young people in Scotland . It provided extra support for children in care and care leavers, and created systems to identify and respond to child welfare concerns at an early stage.

The National guidance for child protection in Scotland was published to provide a statutory framework for agencies and practitioners working together to safeguard children (Scottish Government, 2014). 16

Professor Alexis Jay led an independent inquiry into child sexual abuse in Rotherham. The report estimated that 1,400 children in Rotherham had been sexually abused between 1997 and 2013. Most of the victims were White British children, and most of the perpetrators were from minority ethnic communities.

> Read the independent inquiry into child sexual exploitation in Rotherham on our library catalogue

2015 – Abuse inquiries in England, Wales and Scotland, legislation in Northern Ireland and FGM reporting in England and Wales

The Independent Inquiry into Child Sexual Abuse in England and Wales (IICSA) officially launched to consider the growing evidence of institutional failures to protect children from child sexual abuse (IICSA, 2018). 17

The Scottish Child Abuse Inquiry began investigating the abuse of children in care in Scotland .

The Children’s Services Co-operation Act (Northern Ireland) 2015 required public authorities to contribute to the wellbeing of children and young people in regards to physical and mental health, learning and achievement and living conditions.

Section 74 of the Serious Crime Act 2015 placed a mandatory reporting duty on regulated health and social care professionals and teachers in England and Wales to make a report to the police if:

• they are informed by a child that they have undergone female genital mutilation (FGM)
• they observe physical signs that an act of FGM may have been carried out on a child.

2016 – Football Association inquiries

The Football Association (FA) launched an internal review following allegations of child abuse (FA, 2017). 18

> Read the English Football Association's internal review via our library catalogue

The Scottish FA produced an interim report of the independent review of sexual abuse in Scottish football (PDF) which addresses a large number of issues and made 96 recommendations for change (Scottish Football Association, 2018). 19

> Read the findings from the interim report of the independent review of sexual abuse in Scottish football via our library catalogue

2017 – UK wide protection from online pornography, social care act in England and guidance and an inquiry report in Northern Ireland

The Digital Economy Act 2017 extended protection from online pornography by allowing sites which display pornography to children to be blocked in the UK.

The Children and Social Work Act 2017 made several reforms to the child protection system in England . It established the Child Safeguarding Practice Review Panel to review and report on serious child protection cases and replaced the model of local safeguarding children’s boards (LSCBs) with local safeguarding partners.

The Department of Health in Northern Ireland published an update to the statutory guidance Cooperating to safeguard children and young people (Department of Health, 2017). 20

The Historical Institutional Abuse Inquiry (HIA) in Northern Ireland published its final report (HIA, 2017). 21 Recommendations included a public apology, a redress board, a compensation scheme and a statutory commissioner for survivors of institutional childhood abuse (COSICA).

2018 – Updated Working together guidance in England and Domestic Abuse Act in Scotland

An updated version of Working together to safeguard children (DfE, 2018) was published for England , replacing Local safeguarding children boards (LSCBs) with safeguarding partner arrangements. 22

The Domestic Abuse (Scotland) Act 2018 made it a statutory aggravation for domestic abuse to involve or affect a child (this includes a child hearing, seeing or being present during an abusive incident).

2019 – New guidance in Wales and UN rights in Scotland

The Wales Safeguarding Procedures were published to provide guidance on safeguarding children and adults who are at risk of abuse and neglect (Wales Safeguarding Procedures Project Board, 2019). 23

The Crown Prosecution Service (CPS) recognised breast flattening (the practice of using hard or heated objects to suppress or reverse the growth of breasts) as a form of child abuse in England and Wales (CPS, 2019). 24

The Scottish Government announced its intention to incorporate the United Nations Convention on the Rights of the Child (UNCRC) into Scottish law (Scottish Government, 2019). 25

2020 – Safeguarding during coronavirus and corporal punishment made illegal in Jersey and Scotland

The conditions created by the coronavirus (COVID-19) pandemic meant that everyone working with children and families had to adapt the way they keep children safe. Governments in all four UK nations published a range of safeguarding and child protection guidance during the pandemic.

In the States of Jersey , the Children and Education (Amendment) (Jersey) Law 2020 came into force in April 2020. This abolishes the defence of reasonable corporal punishment of a child.

The Scottish Government abolished the defence of reasonable chastisement from November 2020 under the Children (Equal Protection from Assault) (Scotland) Act 2019 .

The Disclosure Scotland Act 2020 received royal assent in July 2020. This aimed to improve the system for checking the criminal history of people who work with children in  Scotland .

> Find out more about equal protection from assault

2021 – New guidance in Scotland, sexual abuse in schools in England and Wales

The Scottish Government published revised and updated non-statutory National guidance for child protection in Scotland , which replaced the 2014 version and had a strengthened focus on Getting it right for every child (GIRFEC) and children’s rights (Scottish Government, 2021). 26 This guidance has itself now been updated (Scottish Government, 2023). 27

Ofsted published a rapid review of sexual abuse in schools and colleges in England (Ofsted, 2021) 28 . The review was requested by the government after children and young people shared anonymous accounts of their experiences of sexual assault and harassment at school and university on a website called 'Everyone’s Invited'. The report focussed on incidents of peer-on-peer sexual harassment, sexual violence, and online sexual abuse. It summarised findings and recommendations for school and college leaders, multi-agency partners, and the government.

> Read our CASPAR briefing on the review of sexual abuse in schools and colleges in England

In December Estyn published its report looking at the incidence of peer-on-peer sexual harassment in secondary school pupils in Wales (Estyn, 2021) 29 . The report set out nine recommendations to the Welsh Government, local authorities and secondary schools.

2022 – Corporal punishment made illegal in Wales, independent review of children’s social care in England, Independent Inquiry into Child Sexual Abuse (IICSA) recommendations for England and Wales and the national review into the murders of Arthur Labinjo-Hughes and Star Hobson

The Welsh Government abolished the defence of reasonable punishment from March 2022 under the Children (Abolition of Defence of Reasonable Punishment) (Wales) Act).

The independent review of children’s social care published its final report on the children’s social care system in England (MacAlister, 2022) 30 . The UK Government set out the initial measures it would take to improve children’s social care following the publication of the report, which included setting up a National Implementation Board to advise on reforms (DfE, 2022) 31 .

> Read our CASPAR briefing on the independent review of children's social care final report

The Child Safeguarding Practice Review Panel (the Panel) published a safeguarding practice review 32 into the murders of Arthur Labinjo-Hughes and Star Hobson (Child Safeguarding Practice Review Panel, 2022b). The review examines the circumstances leading up to their deaths and sets out recommendations and findings for national government and local safeguarding partners for improving practice.

> Read our CASPAR briefing on the national review into the murders of Arthur Labinjo-Hughes and Star Hobson

The Independent Inquiry into Child Sexual Abuse (IICSA) published its final report into child sexual abuse and exploitation in institutions in England and Wales (IICSA, 2022) 33 . The report sets out findings and common themes arising from the work of the Inquiry and made 20 recommendations for reform for the UK and Welsh governments and other institutions.

2023 – Government responds to IICSA’s recommendations, sets out plans to reform children’s social care in England and updates Working together guidance

In February 2023, the DfE launched a consultation on its long-term plan for the reform of children’s social care in England - Stable homes, built on love (PDF). 34

> Read our CASPAR briefing summarising the government’s strategy

The Welsh Government 35 and the Home Office 36 set out how they would be responding to IICSA’s recommendations.

> Read our CASPAR briefing on the IICSA final report and government responses

The DfE responded to the independent review of children’s social care’s recommendations with a long-term plan for the reform of children’s social care in England, Stable homes, built on love (PDF). 34

>  Read our CASPAR briefing summarising the government’s strategy

As part of these planned reforms, the DfE published updated Working together to safeguard children 2023 , 37 guidance on multi-agency working to help, protect and promote the welfare of children in England.

> Read our CASPAR briefing Working together to safeguard children 2023

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Related resources

Child protection plan register statistics.

Our series of factsheets pulls together the most up-to-date statistics on children who are the subject to child protection plan or on a child protection register for each of the UK nations.

> View all our factsheets

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For further reading about the child protection system in the UK, search the NSPCC Library catalogue using the keywords “child protection”, “child protection services”, “child law”, “social policy”, “United Kingdom”.

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The Victoria Climbié Case

On 25th February 2000, Victoria Climbié is declared dead after several months of never-ending abuse and neglect. The torture she suffered includes starvation, cigarette burns, repeated beatings with bike chains and belt buckles, and hammer blows to her feet.

However, the London doctors who declare this little girl dead believe her name is Anna.

VICTORIA BECOMES ANNA

Victoria Climbié is born on 2nd November 1991 in a small village called Abobo, near Abidjan, the former capital of the Ivory Coast. Victoria smiles, sings and dances as naturally as other children walk and talk. In fact, she is proficient at speaking both her local language and French. Victoria is definitely the entertainer of the family and her parents want the very best for her. But their country is in the midst of civil wars, has endemic levels poverty, and illiteracy is extremely high amongst women.

Adam: the boy whose torso was found in the Thames

So when, shortly before Victoria’s seventh birthday, her 42-year-old great aunt offers to take their daughter back with her to France, it’s the opportunity of a lifetime.

'She was the head of the family at the time. She was a French citizen, apparently, from their perception, incredibly wealthy. One of the analogies is…somebody offering you to send your child to Eton and Harrow and then educate them at Oxbridge.' - Margo Boye-Anawomah, Barrister for Mr and Mrs Climbié

Unknown to them, Marie-Therese (Victoria's great aunt) only wants the child to help her access better state benefits, as she believes having a child will prioritise her on things like housing lists. She had already tried to take a girl from Anna from another family and had a fake passport created in her name, but her parents eventually refused to let her go. Marie-Therese decides it's easier to recruit another child than change the passport.

Therefore, she targets Victoria and gives her hair extensions to make sure she matches that passport and gets through border control.

Within 18 months, Marie-Therese, along with her new bus driving boyfriend, will be responsible for killing ‘Anna’ . Many will blame the Haringey social worker, Lisa Arthurworrey, for not doing more to prevent the abuse. But in reality, she will be just a scapegoat for a system that utterly fails to protect an innocent child.

Marie-Therese first takes Victoria to Paris, France. There she uses Victoria to fraudulently access child-benefit. Required to send her ‘daughter’ to school, Victoria only attends half the time. Marie-Therese has started abusing Victoria.But the authorities threaten action over Victoria’s non-attendance. So after five months, Marie-Therese flees with Victoria.

In April 1999 they arrive in Ealing, West London.Victoria speaks no English.Between 26 April and 7 July, Marie-Therese visits social workers 14 times trying to secure housing support. Victoria is with her on seven visits. One staff member thinks her dishevelled appearance is akin to a child on an ‘Action Aid poster’. But sometimes applicants present themselves as worse off than they are to secure sympathy and money.This is the first chance to save the life of Victoria. There will be eleven more.

That June, Esther, a distant relative of Marie-Therese’s, anonymously rings Brent social workers saying she fears Victoria’s being abused. She’d seen Victoria soon after her arrival and so later notices a new scar. Marie-Therese explains Victoria fell on an escalator. Esther’s suspicious. So she visits them and is shocked to see how much weight Victoria has lost. Esther makes another call to Brent to check on progress and is reassured. A non-professional, non- specialist member of the public has noticed abuse and raised the alarm. Nothing is done.

In early July, Marie-Therese moves them into the Tottenham, North London flat of her new boyfriend, Carl Manning, a bus driver in his late 20s. She secures work so leaves Victoria with a child minder and her children. One of them, Avril, becomes so concerned over Victoria’s mounting injuries, she takes her to hospital. Following a two hour examination the doctor points along Victoria’s thigh:

Doctor: Do you know what these marks are?’

Avril:    No

Doctor:  These are cigarette burns

But the following morning, a senior consultant diagnoses scabies, an infectious disease that causes rashes on the skin. It’s accepted that Victoria’s been scratching herself because of scabies and the injuries are self-inflicted.

Marie-Therese takes Victoria home. Later that month, she’s admitted to North Middlesex Hospital suffering from scalding to her head and face. Marie-Therese explains Victoria tried to get rid of the scabies by holding her head under scalding water. The injuries are horrific.One thing shines through the appalling facial disfigurement the photos record. Victoria is still smiling. And nurses take to her as she recuperates and give her a pair of pink wellies to play in. Her twirling figure down the wards entrances everyone.

But nurses note a change when Marie-Therese arrives. They record the relationship is more like ‘master and servant’ rather than ‘mother and daughter’. Other notes record a belt buckle mark on her body. Once, Victoria is so frightened when Marie-Therese arrives, she wets herself.And during her fortnight hospital stay, social services never once ask Victoria what happened. Marie-Therese takes her back. Doctors now believe Victoria is being abused but mistakenly think the police and social services are also aware of this. A Police Constable is assigned to check up on Victoria. But PC Karen Jones doesn’t visit because she fears catching scabies from the furniture. And no health visitor makes a follow up visit after Victoria’s hospital admission.As they’re now living with Carl, they’re considered the problem of his council, Haringey. Her assigned social worker is Lisa Arthurworrey. She’s just qualified with only 18 months experience. She needs to be closely supervised. She isn’t.

In August, Lisa makes her first of two visits to Carl Manning’s flat. The flat’s better than many she sees. It’s neat, clean and Victoria’s well presented. Lisa doesn’t speak to Victoria, however, or address the fact she’s not receiving education.

Lisa’s second visit, in October, is just days after Carl starts forcing Victoria to sleep in the bath every night. Fear and the beatings mean she’s become incontinent. She soaks the sofa on which she sleeps. So Carl makes her go to bed in a bin liner in the bath. Her hands are tied and then she’s tied into it. So she sleeps in her own excrement in a room without heat or light. It’s now winter.They place food on a plastic plate. But her hands are tied.“Victoria could only eat by pushing her face into the plate like a dog might, except of course, dogs aren’t normally tied up in black bin liners.

'Neil Garnham QC (Counsel to the Inquiry)In November, Marie-Therese rings Haringey social services hysterically alleging Carl’s sexually assaulted Victoria. Three days before, Lisa told her they’ll only get better housing if Victoria’s at risk. Marie-Therese turns up at social services with Victoria. And her alleged abuser, Carl. When it’s explained to Marie-Therese that before she’ll receive her new council flat, Victoria will need to be examined, and Carl arrested, she withdraws the allegations. Haringey decide to arrange another meeting rather than investigate. There are 15 actions that Lisa should next do and she does them. She rings, writes, leaves messages and even tries to visit after work, in her own time. All are ignored.For the remaining four months of her short life, Victoria is on her own. She is starved and tortured daily.

Marie-Therese takes her to church where she says Victoria’s condition has been caused by devils.

On 24 February, Marie-Therese takes Victoria to church again. A member of the congregation sees Victoria and insists she’s taken to hospital.

On 25 February 2000, with no successful contacts made with Victoria, Haringey close the Victoria Climbié case.“Complete Appropriate Paperwork. Then NFA”Management instructions to Lisa regarding Victoria. ‘NFA’ stands for No Further Action.That afternoon, at 3:30pm, in a London hospital, doctors declare an eight year old girl dead.

NOTE: The twelve instances where intervention could have saved Victoria are numbered below:

October 1998: Marie-Therese Kouao proposes to take Victoria back to France for a better life. What this head of the family is offering her parents is a life changing opportunity. Her parents buy Victoria a new pink tracksuit for the colder weather and send her off with her favourite doll.

April 1999: Marie-Therese arrives in England with her ‘daughter’ , ‘Anna’ .

*1* Spring 1999: Marie-Therese visits social workers seven times with Victoria. They’re concerned by Victoria's appearance and the pair's relationship.

*2* June 1999: Ester Ackah, a distant relative by marriage of Marie-Therese anonymously rings social workers warning them that she suspects abuse. She notices little blisters around Victoria’s hairline where she wore a wig but Marie-Therese explains Victoria’s had an accident with some hot water. Senior social worker Edward Armstrong later denies his team received details of a serious child protection case. He says they were told of a child not being in school.

*3* 14 July 1999: Victoria is admitted to Central Middlesex hospital. Avril Cameron, the daughter of Victoria’s childminder, believes Victoria has been scratched and cut. Dr Ekundayo Ajaye-Obe doesn’t believe Marie-Therese’s explanation that Victoria has been scratching at scabies scars. But a consultant paediatrician, Dr Ruby Schwartz overrules him. Another doctor writes a letter saying there were no child protection issues

*4* 15 July 1999: Marie-Therese visits Ealing Social Services but they consider the case a housing issue, and close it. Marie-Therese moves Victoria in with Carl Manning. His three room flat has only a kitchen, a living room with a bed in it and a bathroom. Victoria sleeps in the bath.

*5* 24 July 1999: Victoria is admitted to North Middlesex Hospital suffering from scalding to her head and face. Over the next two weeks of her hospital stay, Social Services never ask Victoria what happened. She’s again taken back by Marie-Therese. As they’re now living with Carl, it’s considered Haringey’s problem. PC Karen Jones doesn’t visit Marie-Therese or Carl because she fears catching scabies. Doctors now believe that Victoria is being abused but mistakenly believe that the police and social work are aware of this situation.

The trial of Louise Woodward: What really happened to baby Matthew?

*6* 5 August 1999: Barry Almeida, a senior Haringey social worker refers Victoria’s case to the Tottenham Child and Family Centre. The Centre looks at the notes and are confused but when they try to clarify them, they’re told the family has moved and the case is closed. Mr Almeida says he doesn’t remember this subsequent conversation.

*7* After the hospital admission, there is no health visitor follow up

*8* 13 August 1999: Mary Rossiter, the consultant paediatrician at North Middlesex Hospital writes to Petra Kitchman, Haringey’s child protection link with the hospital saying she has ‘enormous concerns’. Ms Kitchman says she doesn’t receive the letter for the next seven days. When she does, she says she tells Victoria’s social worker. Lisa Arthurworrey denies this.

*9* 16 August 1999: Social worker Lisa Arthurworrey makes her first of two visits to Carl Manning's flat. Her second will be just days after he starts forcing her to sleep in the bath. She doesn’t speak to Victoria or address the fact she’s not receiving an education.

*10* 2 September 1999: Rossiter again writes to Kitchman, but the latter is on leave. When she returns, Kitchman says she raises this with Arthurworrey. Arthurworrey denies this.

28 October 1999: Lisa Arthurworrey visits Carl and Marie-Therese again to say their housing application has been unsuccessful. The coached Victoria asks 'Why can’t you find us a home. You do not respect my mummy.’ Lisa explains she can only find accommodation if Victoria is at risk.

*11* 1 November 1999: Marie-Therese rings Haringey social services alleging that Carl’s sexually assaulted Victoria. Despite withdrawing the allegation, Haringey decide to arrange a meeting. A vital opportunity for the police and social services to investigate is missed.

*12* 23 December 1999: Ms Arthurworrey makes one of three unsuccessful visits to Carl’s flat. Thinking, without any evidence, that the pair have returned to France, she writes in her notes, they had ‘left the area’.

24 February 2000: Victoria is rushed to North Middlesex Hospital suffering from malnutrition and hypothermia. Her core temperature is so low, doctors can’t read it on their normal equipment.

25 February 2000: In the early hours, she is transferred to the intensive care unit at St Mary’s Hospital, Paddington. Victoria Climbié, utterly let down by the system supposed to protect her, finally gives into the months of abuse and neglect, and is declared dead.

26 February 2000: Marie-Therese and Carl Manning are arrested.

March 2000: Lisa Arthurworrey and her manager Angella Mairs are suspended on full pay.

November 2000: Marie-Therese and Carl Manning's trial begins.

12 January 2001: Nearly a year after Victoria’s death, Carl and Marie-Therese are found guilty of her murder. Both are sentenced to life imprisonment.

May 2001: Lord Laming inquiry begins

9 July 2002: Lord Laming attacks Denise Platt, head of the Social Services Inspectorate for not submitting a vital report about the competence of Haringey Social Services. She apologises but doesn’t attend the hearing.

August 2002: Carole Baptiste, one of the key social workers in the case, is found guilty of failing to attend the inquiry and is fined. Lisa had attacked Carole, her boss, earlier. She says she spent her staff supervision time talking about what it meant to be a black woman and her relationship with God. Carole fails to respond to these allegations and becomes the first person ever to be prosecuted and fined for failing to give evidence at a public inquiry. When she finally does take part, she fights back against Lisa but admits she didn’t read Victoria’s file properly and asks her parents for forgiveness.

12 November 2002: Lisa Arthurworrey and her manager Angella Mairs are dismissed for gross misconduct following disciplinary proceedings

17 July 2008: Berthe Climbié , Victoria’s mother, rebukes criticism of her for letting Victoria go with Marie-Therese. She explains how the African extended family places much more trust in relatives than in the West. She remembers how Marie-Therese held up a bible and swore on it to convince them.

The Aftermath

Health Secretary Alan Milburn addressed the House of Commons stating:  "This was not a failing on the part of one service; it was a failing on the part of every service."

The whole child protection system is overhauled. A new act of parliament is brought in and new guidance issued to social workers.

The government sets up a regulatory agency, the General Social Care Council, as well as the Social Care Institute for Excellence, designed to promote higher standards of practice. Child protection officers in the Met have had a lowly status as shown by their nicknames, ‘The Cardigan Squad’ or ‘The Baby Sitters’. Their training and relevance is now seen as vital.

Victoria’s father, Francis Climbié, says he doesn’t regard Victoria’s life as ‘lost’ because of the chance it created to change childcare for the better. He and his wife start a campaign to build a school for children in the Ivory Coast. It’s hoped that by providing education there, other parents won’t feel the need to let their children be taken away.

That dream has since become a reality and their newly built school now teaches 360 children. Victoria was finally laid to rest in her hometown in the Ivory Coast.

'Do not let Victoria's death be in vain' - Francis Climbié

The Investigation

An eight year old girl has died despite being seen by dozens of social workers, nurses, doctors and police officers before she dies. All failed to spot and stop the abuse as she was slowly tortured to death.

In April 2001, the government announces a public inquiry. It is the first in Britain to use special powers to look at everything from the role of social services to police child protection arrangements.

A former chief inspector of social services, Lord Laming, heads the public inquiry into a case he calls the worst case of neglect of which he’s ever heard. Victoria’s parents fly over and attend almost every day of his inquiry. As witnesses in the criminal trial, they’ve been excluded from much of the evidence of how their daughter died. The details of their daughter’s injuries are sometimes too hard to bear.In the first phase, it takes the testimony of more than 230 witnesses and in an unprecedented move it recalls the killers, Carl and Marie-Therese.

'It was an absolute pantomime from the minute she walked into the room.'Margo Boye-Anawomah, Barrister for Mr and Mrs Climbié

Marie-Therese shrieks at the top of her voice, refusing to sit down, and when she does, despite being a convicted murderer, she denies any blame. Unbelievably, she tries to shift that onto those most undeserving. She turns on the parents of Victoria accusing them of not being properly married.

The barrister Neil Garnham exposes incompetence at every level as he interrogates the witnesses.

One of those witnesses is Lisa Arthurworrey, Victoria’s social worker. She is obviously in a very fragile state. The press has spent the intervening time demonising her. Lisa was responsible for Victoria for the last seven months of her life. In this time, Lisa saw her for a total of just 30 minutes. But she has been made a scapegoat for a complete system failure.

Victoria’s Haringey social worker wasn’t evil. The truth was, she was young, inexperienced, overworked, and incompetently managed.

And two experienced senior doctors are also found to have failed Victoria. When Victoria’s child minder first admitted her to hospital, fearing abuse, it was Consultant Paediatrician, Dr Mary Schwartz who decided her cuts were due scabies. Two weeks later, when Victoria returned to hospital, the consultant, Dr Mary Rossiter did think Victoria was being abused, but confused colleagues by writing, ‘able to discharge’ on her notes.

In total there were 12 missed opportunities where professionals could have acted to save Victoria. Warning phone calls never followed up on, checks not made on stories told by Victoria’s great aunt, medical misdiagnoses and throughout, a total failure to engage with the little girl who should have been the centre of everybody’s concern. Her views were never sought.

There were also management failings. Middle ranking and senior staff did not have in place proper systems to monitor, support and supervise inexperienced subordinates. Haringey social services are described as shambolic, underfunded, and mismanaged.

Lord Laming’s inquiry identifies social services departments at four London boroughs, two police forces, two hospitals, and a specialist children’s unit who all failed to act when presented with evidence of abuse. The failings were he believed, ‘a disgrace’.“In most cases, nothing more than a manager reading a file, or asking a basic question about whether standard practice had been followed, may have changed the course of these terrible events”Lord LamingAfter two years, Lord Laming concludes that a radical reform of child protection services is needed and especially that there should be a children’s commissioner to head a national agency. He concludes that it’s not a lack of law, but a lack of its implementation that has allowed the tragedy.

Both Carl and Marie-Therese go to the Old Bailey in November 2000. Their trial lasts just over two months. They, and the ‘blindingly incompetent’ child protection authorities, are to be judged. Carl denies murder but pleads guilty to child cruelty and manslaughter. Marie-Therese denies all charges.

'Marie-Therese defence was that Victoria’s condition was due to the fact that she was possessed by demons. And she maintained that throughout. Carl Manning, realising from an early stage that he was probably going to have to accept his responsibility for ill-treating this child; his defence was, ‘although I am responsible for injuring her, at the time I injured her, I didn’t intend to cause her really serious bodily harm, and I certainly didn’t intend to kill her.' Sally Howes QC, Counsel for the prosecution

Some of Carl’s statements are almost incomprehensible.

'You could beat her and she would not cry at all. She could take the beatings and pain like anything.'

But while Carl does show some shame, Marie-Therese shows no remorse for her actions. And her behaviour in court shocks everyone:

'The way she chuckled in such a menacing way and laughed dismissively, yes, it made the hairs stand on the back of my neck. This is the only time I have genuinely felt myself in the presence of evil.' Sally Howes QC, Counsel for the prosecution.

It is during the trial that it emerges that Marie-Therese used a hammer to break Victoria's toes.But neither Carl nor Marie-Therese once give a satisfactory explanation as to why they treated Victoria as they did. One suggestion is that Marie-Therese thought she may be able to access more benefits with a child. When this did not happen, she took her frustrations out on the child.

The jury takes four days to convict. Almost a year after Victoria’s death, they find both defendants guilty. Both are sentenced to life imprisonment.In an unprecedented move, they will both have to give evidence at another inquiry.

On admission, Victoria’s core temperature was so low doctors didn’t have any instruments with the capacity to record it.Dr Nathaniel Carey, the Home Office pathologist assigned to examine Victoria finds 128 injuries. He believes it to be,‘…the worst case of child abuse I’ve encountered'.

Marie-Therese is immediately arrested at the hospital and a murder investigation is launched. Police interview her but find her evasive and obstructive. She doesn’t co-operate in any way.

The following day, Carl is arrested at his flat. In his police interview, detectives are shocked by his openness. He talks of punching Victoria or of using a shoe to beat her. Other times, he’d take a bicycle chain to her body and head.During police interviews both claim that Victoria was possessed by demons.

Detectives search their flat for forensic evidence and find Carl’s tried to cover up evidence of the abuse by cleaning it with bleach. Despite this, they recover blood samples from the bath and the walls. And there’s blood on the furniture in the living room; And in the bedroom.

'We managed to recover many, many samples of blood. Now, given that they had already been cleaned I think that gave an indication of exactly what had happened there. She had been assaulted regularly and severely and she had bled and even though they had attempted to cover this up, it must have been in abundance.'

Detective Superintendent Keith Niven, Metropolitan PoliceIn the bins, they find the discarded tapes used to bind Victoria’s feet and wrists.They also find a passport in the flat which seems to confirm the dead girl as Anna. But detectives soon realise the photo in the passport isn’t that of the girl who’s lying in a London mortuary.They manage to track down and contact her real parents by establishing which family Marie-Therese targeted. Victoria’s parents then have to make the terrible 3,000 mile journey to identify their dead daughter.

Carl Manning and Marie-Therese Kouao are charged with the murder of Victoria Climbié.

What drove James Bulger's underage killers?

Children's safeguarding case study: Victoria Climbié

In February 2000, a London minicab driver was called to a church in the old Rainbow Theatre on Seven Sisters Road and asked if he’d take 8 year old Victoria and her aunt to hospital as the pastor was concerned about Victoria’s state of health. Mr Salman Pinarbasi, the mini-cab driver, was so concerned about Victoria he took her to the nearby Tottenham Ambulance Station. She was then taken by ambulance to the North Middlesex Hospital and admitted. Victoria had hyperthermia, multiple organ failure, the staff could not straighten her legs and said she had injuries too numerous to record. After hours of intensive care treatment, multiple cardiac arrests and attempts to resuscitate her, she sadly died that night.

This had not been Victoria’s first visit to hospital. She had previously been taken there by an unregistered childminder who was concerned about injuries she had arrived with. These were wrongly diagnosed after admission as scabies. Victoria was also admitted on a later date as according to her aunt, she’d scalded her own head and face. After two weeks in hospital she was discharged and lived again with her aunt and her aunt’s boyfriend for the last 7 months of her life.

‘1.4 Victoria spent much of her last days, in the winter of 1999–2000, living and sleeping in a bath in an unheated bathroom, bound hand and foot inside a bin bag, lying in her own urine and faeces. It is not surprising then that towards the end of her short life, Victoria was stooped like an old lady and could walk only with great difficulty.’ excerpt from the Victoria Climbié Inquiry

Victoria Adjo Climbié (2 November 1991 – 25 February 2000) was born in Abobo, Côte d’Ivoire, and left the country with her great-aunt Marie-Thérèse Kouao, a French citizen, to be educated in France with the permission of her parents. They arrived in London in April 1999. It is not known exactly when Kouao began abusing Victoria, although it is suspected to have worsened when Kouao met and moved in with Carl Manning, who became Kouao's boyfriend. During the abuse, Victoria was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. Victoria was known to the police, social services departments of four local authorities, the National Health Service and the National Society for the Prevention of Cruelty to Children abuse. Her lack of school registration and attendance was not addressed. In what the judge in the trial following Victoria's death described as "blinding incompetence", all failed to properly investigate what was happening and little action was taken. Kouao and Manning were convicted of murder and sentenced to life imprisonment.

After Victoria's death, a public inquiry, chaired by Lord Laming, was ordered. Hundreds of witnesses were interviewed and numerous instances where Victoria could have been saved were outlined. It was noted that many of the organisations involved in her care were badly run, and that there were concerns about possible racial and cultural sensitivities surrounding the family and case, as many of the participants were black. The subsequent report by Laming made 108 recommendations related to children’s safeguarding in England. The Inquiry also prompted the creation of the Office of the Children's Commissioner chaired by the  Children's Commissioner for England .

Adults involved included:

Social workers, housing officers, police officers, church workers, her aunt, health workers, minicab driver, and an un-registered childminder.

Further reading

• The Victoria Climbié Inquiry Summary Report of an Inquiry by Lord Laming
• Victoria Climbié Inquiry

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