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Tuesday 28 January 2003

The Report of the Victoria Climbié Inquiry was published today (28th January 2003). It follows three Inquiries using powers under the Children Act 1989, NHS Act 1977 and Police Act 1996. The public inquiry was set up following Victoria Climbié's tragic death on 25 February 2000 and the subsequent murder conviction of her carers, Marie-Therese Kouao and Carl Manning, in January 2001.

Victoria came into contact with four social services departments, three housing departments, two specialist child protection teams of the Metropolitan Police, two hospitals and a families centre managed by the NSPCC.

The Report details a catalogue of administrative, managerial and professional failure. It outlines a number of occasions upon which the most minor and basic intervention on the part of the staff concerned could have made a material difference to the eventual outcome. Many of the concerns identified in Victoria's case are replicated elsewhere in the country.

In Lord Laming's view, Chairman of the Inquiry, "the legislative framework is fundamentally sound. The gap is in its implementation. Having considered all the evidence it is not to the often hapless front-line staff that I direct most criticism for the failure to protect Victoria. True their performance often fell well short of an acceptable standard of work. But the greatest failure rests with the senior managers and members of the organisations concerned whose responsibility it was to ensure that the services they provided to children such as Victoria were properly financed, staffed and able to deliver good quality services to children and families. They must be accountable."


The Report outlines three areas:

  • a fundamental change in the mind-set of managers in key public services, who must see their role in terms of the quality of services delivered at the front door rather than in administrating bureaucratic and sometimes self-serving procedures

  • a clear and unambiguous line of managerial accountability both within and across public services

  • the current arrangements of Area Child Protection Committees or any proposal for a national child protection agency, should be replaced by a new National Agency for children and families. This Agency should have powers to ensure that all of the key services affecting children and families - health, housing and police - carry out their duties in an efficient and effective way. The Chief Executive of this agency could undertake the functions of a Children's Commissioner for England. The Agency should report to a new ministerial committee for services to children, chaired by a minister of cabinet rank who would be responsible for ensuring that policies, legislation and departmental initiatives affecting children and families are properly considered, financed and co-ordinated. Similar arrangements need to operate at a local level.

Lord Laming said, "It is an agenda for action now. The Report contains some 108 recommendations. Of those, 46 should be implemented in three months and a further 38 in six months. Some of the recommendations are disarmingly self-evident - and for the most part should be current good practice. That they have had to be made should be a reproach to everyone with responsibility for the safety of children. Now is the time for every chief executive to conduct a thorough audit of the quality and effectiveness of services to children and families and to have in place - before summer - an action plan to speedily remedy any defects. Nothing less will do.

"The best that we can hope for from the terrible ordeal suffered by Victoria, who was brought to this country for a better life, is that this Report is the last of its kind and that, in future, the aspiration of the legislation will be reflected in day by day practice across the country. That is the challenge to us all." LORD LAMING handed his report into the death of Victoria Climbié to the Government on 6th January 2003. The Government will set a date for publication in due course.

Notes to Editors

Terms of Reference (full details in the Report)
To establish the circumstances leading to and surrounding the death of Victoria Climbié;
to reach conclusions as to the circumstances leading to Victoria Climbié's death and make recommendations to the Secretary of State for Health and to the Secretary of State for the Home Department as to how such an event may, as far as possible, to be avoided in the future.

For further information

Please contact Victoria Climbié Inquiry press office on:
07904 030 404
Fax: 07904 030 268

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