Why Victoria? 

On 2nd November 2021 Victoria would have celebrated her 30th birthday, a milestone occasion for any adult and a time to be celebrated.  In her memory and to mark what would have been an important birthday, I have chosen to dedicate my article to Victoria.  This subject strikes a particularly poignant chord for me as I like to think the start of my career as a child protection lawyer was in some part down to a (good!) presentation I gave to my interview panel for the role of assistant solicitor with Knowsley Council, which I based on the Climbié Inquiry.   

It may be a sombre article, but it is important that we do not allow the memory of this little girl to be lost as we continue to move forwards with our own lives.  Important changes and developments in child protection procedures came about because of the public inquiry into Victoria’s death, these changes have acted as a springboard for further improvements to the system to ensure that we continue to put the welfare needs of children at the forefront of what we do. 

Who was Victoria Climbié? 

“Victoria had the most beautiful smile that lit up the room.” Patrick Cameron (i) 

Victoria Climbié was born to parents Francis and Berthe Climbié on 2nd November 1991 in Abobo, Côte d’Ivoire (Ivory Coast, South-West Africa).  In 1999, Victoria left her parents’ care with her great-aunt Marie-Thérèse Kouao, initially for France and later arriving in London.  The intention was for Victoria to be afforded a better standard of education and quality of life than what she might have received had she remained in Africa.  Sadly, little did her parents know that sending their little girl away would not result in the better life she entirely deserved, but rather it would end in her murder by the person who was entrusted with caring for Victoria, her great-aunt Ms Kouao and her boyfriend Carl Manning.  Victoria tragically died on 25th February 2000 at St Mary’s Hospital Paddington from severe organ failure because of the sustained physical abuse she had been subjected to. 


“All non-accidental injuries to children are awful and difficult for everybody to deal with, but in terms of the nature and the extent of the injury, and the almost systematic nature of the inflicted injury, I certainly regard this as the worst I have ever dealt with, and it is just about the worst I have ever heard of.” (ii)  

Victoria was regularly beaten by her great-aunt including having her toes hit with a hammer.  Blood was also found on Manning’s football boots and he admitted during his trial that he would hit Victoria using a bicycle chain.  Victoria was left to live and sleep in a bath in an unheated bathroom, bound hand and foot inside a bin bag, lying in her own urine and faeces.   

“I had never seen a case like it before.  It is the worst case of child abuse and neglect that I have ever seen.” (iii) 

During Victoria’s post-mortem, no fewer than 128 separate injuries had been sustained. 

The Inquiry 

In April 2001, Lord Laming led the public inquiry into Victoria’s death.  The Report, which was published on 28th January 2003 made 108 recommendations (Part 6 of the Report), divided into ‘General recommendations’ (17), ‘Social Care recommendations’ (46)’Healthcare recommendations’ (27) and ‘Police recommendations’ (18). 

The extremely sad fact is that Victoria’s death was preventable had there been a joined-up approach to the way agencies operated:  

‘Victoria was not hidden away.  It is deeply disturbing that during the days and months following her initial contact with Ealing Housing Department’s Homeless Persons’ Unit, Victoria was known to no less than two further housing authorities, four social services departments, two child protection teams of the Metropolitan Police Service, a specialist centre managed by the NSPCC, and she was admitted to two different hospitals because of suspected deliberate harm.  The dreadful reality was that these services knew little or nothing more about Victoria at the end of the process that they did when she was first referred to Ealing Social Services by the Homeless Persons’ Unit in April 1999.  The final irony was that Haringey Social Services formally closed Victoria’s case on the very day she died.  The extend of the failure to protect Victoria was lamentable.  Tragically, it required nothing more than basic good practice being put into operation.  This never happened.’ (iv)  

Lord Laming concluded that that the Report ‘is a vivid demonstration of poor practice within and between social services, the police and the health agencies.  It is also a stark reminder of the consequences of ineffective and inept management.’ (v)   

Developments in the System – did it get better? 

The Inquiry Report concluded that the child protection framework under the Children Act 1989 was fundamentally sound, but there were gaps in its implementation.  As a result, the Children Act 2004 made several key changes.  Further changes were made by the Children and Social Work Act 2017, which amended the 2004 Act in several areas.  

Among other things, the 2004 Act, as amended:  

  • Places a duty on local authorities in England to make arrangements to promote co-operation with key partners and local agencies, with a view to improving the well-being of children in the authority’s area. 
  • Places a duty on a range of agencies, including local authorities, the police and health services, to ensure that they consider the need to safeguard and promote the welfare of the children when carrying out their functions. 
  • Establishes the roles and responsibilities of safeguarding partners (the local authority, NHS Clinical Commissioning Groups and the Police), which are responsible for determining how safeguarding arrangements should work in their area. vi 

Statutory guidance, ‘Working Together to Safeguard Children’, first published in 2010 and was last updated in July 2018 to reflect the changes arising from the Children and Social Work Act 2017, sets out how individuals and organisations should work together to safeguard and promote the welfare of children and young people in accordance with the relevant legislation.   

Improvements and changes were implemented following Victoria’s death, but the child protection system continued to have deficits, which has been evidenced by the number of child deaths since, including that of Peter Connelly (Baby P) in 2008, following which Lord Laming was commissioned to undertake an urgent progress report in respect of the implementation of effective arrangements for safeguarding children in England. 

In 2011, Professor Eileen Munroe was commissioned to undertake an independent review (The Munroe Review of Child Protection) of child protection in England.  Professor Munroe considered the child protection system to be ‘over-bureaucratised and concerned with compliance’ rather than a system which is child-focussed. 

Our practice 

We as practitioners are important cogs in the child protection system.  So, what can we do to ensure the system continues to function effectively and the dots continue to be connected?  We should ensure that we have availed ourselves of the relevant legislation and statutory guidance in respect of the roles, responsibilities and most importantly the statutory duties of those professionals who become involved in safeguarding a child.  This is with the aim of ensuring that we are in a strong position to be able to (i) give detailed advice to those whom we represent, whether that be a local authority client, Children’s Guardian or parents and connected persons and (ii) to be able to challenge professionals actively and robustly where necessary.  

Final thoughts 

Undoubtedly the child protection system in England and Wales has changed, improved and evolved over the last 21 years since Victoria’s death.  This should not come as a surprise to any of us; this is an area that does not remain static, it is forever changing and adapting to ensure the children it aims to protect are indeed protected.  A system can always be improved upon.  Will it ever be perfect?  I don’t consider perfection exists and the sad reality is that sometimes deficits in the system are brought to the fore when things go tragically wrong.  My hope however is that we never forget the young lives that have been lost due to failings in the system and that the legacy of Victoria and others lives on in the work that we do to ensure better futures and outcomes for those children who find themselves requiring protection. 

“I have suffered too much grief in setting down these heartrending memories.  If I try to describe him, it is to make sure that I shall not forget him.” (vii)

 Written by Lyana Chan, Consultant Barrister, Unit Chambers

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