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 ClimbiéMarie-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.