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In his statement to the House of Commons when presenting Lord Laming’s Inquiry Report into the death of Victoria Climbié, on 28 January 2003, the Secretary of State for Health, Alan Milburn, said:
“It is an all too familiar cry. In the past few decades there have been dozens of inquiries into awful cases of child abuse and neglect. Each has called on us to learn the lesson of what went wrong. Indeed, there is a remarkable consistency in both what went wrong and what is advocated to put it right. Lord Laming’s Report goes further. It recognises that the search for a simple solution or a quick fix will not do. It is not just national standards, or proper training, or adequate resources, or local leadership, or new structures that are needed.”
I will give an overview of the inquiry. I will also give an overview of the themes, lack of accountability right through the organizations to the most senior level and staff not adequately trained in child protection. I will analyse and critique these themes in relation to agency policy, legal requirements, research, practitioner knowledge and the voice of the service user. Previous inquiries and there link to this inquiry will be discussed along with have we learned any lessons from this. The failure to implement a legal, ethical and political framework to inform current best practice will be utilized. I will reflect on the implications of evidence informed practice and how this will inform future social work practice.
This paragraph will provide a summary of the events leading to the death of Victoria Climbie, and establish why there was a need for the inquiry. From the report (Lord Laming, 2003) we know that Victoria Climbie came to England with her great-aunt, Marie-Therese Kouao in April 1999. Within a year, she was dead. On 25th February 2000, Victoria died of hyperthermia at St Mary’s Hospital, Paddington. She was just eight years old and had 128 separate injuries to her body. On 12th January 2001, her great-aunt Kouao and her boyfriend, Carl Manning, were convicted of murder. The level of cruelty experienced by Victoria was truly horrific, with daily beatings using several different implements. Her final days were spent living and sleeping in an unheated bathroom in the middle of winter, where she was bound hand and foot, lying in her own urine and faeces in a bin bag in the bath. The secretary of State set up the independent statutory inquiry into her death, under the Chairmanship of Lord Laming, in April 2001, to establish under section 81 of the Children Act 89 the concerns with the functions of the local authority social services committees and the way they relate to children. The inquiry wanted to examine the way in which local authorities in respect of their social services functions and identify the services sought or required by, or in respect of Victoria, Marie-Therese and Carl.
This section will now aim to analyse and critique the key theme I have identified that emerged from the inquiry report which is lack of accountability right through the organizations to the most senior level and staff not adequately trained in child protection. Lord Laming (2003) points out ‘There were at least 12 key occasions when the relevant services had opportunities to successfully intervene to help Victoria, but had failed to do so.’ Within the Report Lord laming (2003) 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.’ He continues to states Lord Laming (2003) ‘There can be no excuse for such sloppy and unprofessional performance.’ As Lord Laming (2003) 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, what happened to Victoria, and her ultimate death, resulted from an inexcusable “gross failure of the system.’ Lord Laming’s (2003) 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.’
The Inquiry Report (Lord Laming, 2003) highlighted “widespread lack of accountability through the organisations” as the principal reason for the lack of protection afforded to Victoria. Who should be held responsible for these failures? As Webb (2002) states: ‘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, I think that the performance of people in leadership positions should be judged on how well services are delivered at the front door’. Professor Nigel Parton (2003) points out that ‘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. Professor Nigel Parton (2003) continues to state that ‘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. The Inquiry Report Lord Laming (2003) 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. As Rustin (2010) states 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 Lord Laming (2003) 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. Rustin (2004) states this was not a view shared by Lord Laming. Rustin (2004) also continues to state that 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. In addition to the fundamental problems of a lack of accountability and managerial control, it was also apparent in the course of the Inquiry Lord Laming (2003) that other failings existed in all aspects of practice. This section will evaluate previous inquiries and how they link to this inquiry and have any lessons been learned from them. As Rustin (2004) states: ‘As with many previous inquiries into child protection failures, Maria Colwell (1973), Jasmine Beckford (1984), Tyra Henry (1984) and Kimberley Carlile (1986) 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 Lord Laming (2003) ‘Information systems that depend on the random passing of slips of paper have no place in modern services’.
The evidence from another report, Maria Colwell, who had died in January of 1973 pointed to similar weaknesses, which were found in Victoria’s report these weaknesses were, lack of accountability and staff not adequately trained (Corby et al, 2001).
Inquiry reports are sources of evidence to inform social work practice and even though they have many weaknesses within them as illustrated. Professor Nigel Parton (2004) points out that ‘In many respects public inquiries have proved to be the key vehicle through which changes in policy and practice have been brought about over the last thirty years in relation to child protection policy and practice in this country.’ Professor Nigel Parton (2004) continues to point out that ‘Rather than public inquiries being ignored, they have been fundamental to the way child protection operates. In this respect, they are as much a part of the problem as they are the solution.’
Have lessons been learned from the many public inquiries over the previous thirty years. It was as if states Professor Nigel Parton (2004) ‘The frontline professionals, and the key organisations and agencies who have responsibility for children and families were quite incapable of learning the lessons and, crucially, putting these into practice in such a way that such horrendous tragedies could be avoided. It is hoped by many, therefore, that the report by Lord Laming, and the changes brought about as a result, will mean that this will be the last report of its type.’
This section will address the other theme I have highlighted adequate training. The question of adequate training and supervision for staff working in all the relevant agencies were also an issue identified in the Inquiry. Professor Nigel Parton (2004) points out that 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. Professor Nigel Barton (2004) also points out that 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 (Lord Laming, 2003) 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’.
This section will now look at the failure to implement the legal and political framework within the inquiry report. Lord Laming within the report (Lord Laming 2003) 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, Lord Laming (2003) states 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”. Rustin (2004) states ‘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 as pointed out by Rustin (2004) ‘Of recognising the different needs of children’. How the sections were being applied on the ground however as stated by Lord Laming (2003) is ‘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’. The Children Act, Lord Laming (2003) argued to us ‘Should be about promoting the well-being of children, not about putting labels around people’s neck’. Lord Laming (2003) 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 2003) stated ‘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, or who are sufficiently persistent’. Therefore services must be more accessible and they must be more in tune with their local communities. If, as Lord Laming believes Kirton (2009, p.17) states ‘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.’ I believe that the Children Act 1989 remains essentially sound legislation. However, there is concern as pointed out by Professor Nigel Parton (2004) ‘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 (Lord Laming 2003) 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.
Within this section I will discuss the ethical framework. It is important to include the issues of social class and gender, which were not evident in the Victoria Climbié inquiry. However, it is issues around ethnicity and race that are more evident. However, the diversity referred to is incredibly complex. This is illustrated at various points states Webb (2002) For example: ‘At the time Victoria’s case was handled in Brent, all the duty social workers had received their training abroad and were on temporary contracts. (In Brent) at least 50 per cent of social workers time was spent working on cases of unaccompanied minors.’ As Webb (2002) states ‘There was evidence that Haringey has one of the most diverse populations in the country, with 160 different languages spoken locally, a long tradition of travellers settling in the borough and a high proportion of asylum-seeking families (9 percent of the total population).’
Within the report Lord Laming (2003) points out that ‘In relation to all the London boroughs involved there were high levels of poverty and deprivation, diverse ethnic, cultural, linguistic backgrounds, as well as the diverse backgrounds of the workers themselves.’ In many respects, it seems Victoria’s situation was not unique in these respective boroughs. Webb (2002) indicated ‘The impact of increased global mobility, more specifically the rapid increase in asylum-seeking families, together with the diverse backgrounds of the workers themselves increasingly seems to characterise work in many metropolitan areas.’ This has a particular impact states Webb (2002) ‘On the nature, stability and cohesion of local communities.’ It is worth noting that, compared to the Maria Colwell case, no referrals are noted in the Victoria Climbié case from neighbours or other members of the community apart from the ‘child minder’ Mrs Cameron. We are not simply talking about diversity here but incredible complexity. Kirton (2009) argues that ‘Not only does it pose major linguistic challenges but also it poses major challenges for statutory departments in relation to the familial and cultural identities of those with whom they work and to whom they have responsibility.’ Issues around racism are clearly important here, however they cannot be reduced to a simple black and white community and cultural divide.
This section will reflect on the implications of evidence-informed practice (EIP) and the usefulness of the inquiry to inform the development of future social work practice. Often, in hindsight, those who put people at risk are blamed for the misfortune and harm they cause. (Kirton, 2009) This is arguably the most signi¬cant professional context in which EIP has emerged. According to Munro (1998) ‘Social workers rely on vague assessments and predictions, rather than considering what is more or less probable. In everyday life decisions have to be made on a limited evidence base and professional decisions are also at best problematic’. There are numerous unexpected and complex outcomes in social work, many of which rest on having to make judgments under conditions of uncertainty. (Kirton, 2009) The main problems associated with making effective decisions in social work as stated by Kirton (2009) include: risk and uncertainty, intangibles, long-term implications, interdisciplinary input and the politics of different vested interests pooled decision making and value judgments. Decision analysis has developed as a statistical technique to help overcome these kinds of problems. Decision analysis is closely related to risk assessment and actuarial practices. Evidence-informed practice and policy are self-explanatory. They involve the adoption of evidence-based protocols and use local standards for conducting social work practice and developing organizationally speci¬c policies. (Webb, 2002) It has been suggested that evidence-informed protocols feed directly into the practitioner context to provide guidelines for carrying out EIP. Essentially evidence-informed practice and policy in social work will entail the explicit and judicious use of current best evidence in making decisions about the social care of service users. This de¬nition is widely used and derived from Sackett et al.’s ‘Evidence-based Medicine’ (1996). A pragmatic approach as stated by Sackett (1996) ‘Has been adopted here, which regards the practice of evidence as integrating practitioner expertise with the best available external evidence from systematic but multiple research methods.’ The implementation model outlined is the idea that the practice-based process begins with the evidence rather than the individual or groups of clients.
Clearly the application of evidence-informed practice and policies will be governed by the economic scope of social work agencies in terms of resources and the development of an evidence-informed infrastructure. (Kirton, 2009) Sackett (1996) points out that ‘At a local level it will also be dependent on incremental learning and accumulative professional development which are likely to be facilitated by the practice research networks and evidence-based brie¬ngs discussed above.’
In this essay I have analysed and critiqued two key themes from the inquiry, lack of accountability right through the organizations to the most senior level and staff not, adequately trained in child protection. I have also analysed and critique these themes in relation to agency policy, legal requirements, research, practitioner knowledge and the voice of the service user. I have linked previous inquiries and discussed have we learned any lessons from these inquiries. I identified the failure to implement a legal, ethical and political framework to inform current best practice will. I also reflected on the implications of evidence informed practice and how this will inform future social work practice.
A closing quote to finish from the Secretary of State, Alan Milburn (2003)
“It has felt as if Victoria has attended every step of this inquiry, and it has been my good fortune to have had the assistance of colleagues whose abilities have been matched by their commitment to the task of doing justice to Victoria’s memory and her enduring spirit, and to creating something positive from her suffering and ultimate death.”
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