The Victoria Climbié Case

There were 12 chances to save the life of this eight year old girl. Instead, she died of 128 injuries. How could a child in Britain die like this?

There were 12 chances to save the life of this eight year old girl. Instead, she died of 128 injuries. How could a child in Britain die like this?

On 25 February 2000, months of abuse and neglect finally overcome Victoria Climbié and she’s declared dead. The torture she’s suffered includes starvation, cigarette burns, repeated beatings with bike chains and belt buckles. And hammer blows to her toes.
But the London doctors who declare this little African girl dead believe her name is Anna.

VICTORIA BECOMES ANNA
Victoria Climbié is born on 2 November 1991 in a small African village called Abobo which is 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 speaks both her local language and French, as her country is an ex French colony.) Victoria is definitely the ‘entertainer’ of the family. And her parents Francis Climbié and Berthe Amoissi want the very best for her. But their country is often torn apart by civil war, has endemic poverty, and illiteracy is extremely high amongst women.

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

“Kouao was somebody they knew well. 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 only wants Victoria to help her access better state benefits back in France as she believes having a child will prioritise her on things like housing lists. To this end, Marie-Therese has already prepared a false passport in the name of her fictional daughter Anna. But the family of her intended target refused to let their Anna go. And it’s easier for the manipulative Marie-Therese to recruit another child of a different name, than change the passport. So she targets Victoria. To get her through border controls, she gives Victoria hair extensions. She now resembles the photo of Anna, the actual girl in the false passport.

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.

Crimes

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.

Arrest

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 Police

In 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.

Trial

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.

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 Laming

After 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.

Aftermath

“This was not a failing on the part of one service; it was a failing on the part of every service”
Health Secretary Alan Milburn, statement to House of Commons


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 become a reality and their newly built school now teaches 360 children.
And her parents finally laid Victoria to rest in her home town in the Ivory Coast.

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

Timeline

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

7 January 1973
One of the first infamous cases of child abuse is discovered when Maria Colwell, aged seven, is taken to hospital. She is terribly thin and has been badly beaten. Her death leads to a public inquiry that is one of the first major attempts designed to protect children from abuse

October 1998
Marie-Therese Kouao proposes to Victoria’s family to take her 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’

ONE:
Spring 1999

Marie-Therese visits social workers seven times with Victoria. They’re concerned that it’s not a normal mother-daughter relationship, and by Victoria’s appearance

TWO:
June 1999

Ester Ackah, a distant relative by marriage of Marie-Therese anonymously rings Brent 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. Other experts argue non school attendance can be an indicator of abuse. (And it was when Victoria was in France and started failing to attend school)

THREE:
14 July 1999

Victoria is admitted to Central Middlesex hospital as 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 sores. But a consultant paediatrician, Dr Ruby Schwartz over rules him. Another doctor writes a letter saying there were no child protection issues

FOUR:
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. They will make the bath Victoria’s bed.

FIVE:
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.

SIX:
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.

SEVEN: After the hospital admission, there is no health visitor follow up

EIGHT:
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.

NINE:
16 August 1999

Social worker Lisa Arthurworrey makes her first of two visits to Carl Manning 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.

TEN:
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.

ELEVEN:
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.

TWELVE:
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.
Marie-Therese is arrested and the following day, so is Carl Manning.

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

November 2000
Carl and Marie-Therese 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

7 January 2002
Two year old Ainlee Walker is found dead on her parent’s table. Dennis Henry and Leanne Labonte had cruelly starved and abused her until she died of her 64 injuries. Professionals had failed to visit.

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.