Both her guardians, Marie-Thérèse Kouao (born 18 July 1956 in Bonoua, Ivory Coast) and Carl Manning (born 31 October 1972), were convicted of murder and sentenced to life imprisonment at their trial on 12 January 2001.
Born in Abobo, Ivory Coast, Climbié moved to England at the age of seven with her great-aunt Kouao. It is suspected that Kouao started abusing Climbié soon after her arrival in the country, and the abuse worsened when Kouao moved in with Carl Manning. Up to her death, the police, the social services department of many local authorities, the National Health Service, the NSPCC, and local churches all had contact with her, and noted the signs of abuse. However, in what the judge in the trial following Victoria's death described as "blinding incompetence", all failed to properly investigate the abuse and little action was taken. She died in February 2000, aged eight.
Victoria left the Ivory Coast with Kouao "probably some time in November 1998 and travelled to Paris, France, where she enrolled at school. By December 1998, however, Kouao began to receive warnings about Victoria's absenteeism, and in February 1999, the school issued a child-at-risk notification and a social worker became involved. The school noted how Victoria tended to fall asleep in class, and the headteacher later recalled Kouao mentioning Victoria suffering from some form of dermatological condition and that, on her last visit to the school on 25 March 1999, Victoria had a shaven head and was wearing a wig. When they left France, Kouao owed the authorities £2000, after being wrongly paid in child benefit, and it is claimed that Kouao viewed Victoria as a useful tool for claiming benefits.
They travelled to London, England, on 24 April 1999, to the Ealing district. Between 26 April 1999 and 7 July 1999, Kouao visited Ealing social services fourteen times for housing and financial purposes. Victoria was with her on seven occasions. The staff there noticed Victoria's injuries, with one staff member thinking that she looked like a child from an "ActionAid poster", but they did not take any action and may have presumed that Victoria's appearance was a purposeful attempt to elicit sympathy. They lived in a bed and breakfast in Ealing until 1 May 1999, before moving to Harlesden, in the Brent district. Kouao got a job as a hospital cleaner, leaving Climbié to the care of a childminder, Priscilla Cameron, who was unregistered, which the social services did not check. On 14 June 1999, Kouao met Carl Manning, a Ghanaian, on a bus which he was driving, and she and Victoria moved into his one-bedroom flat in Tottenham, in the Haringey district, on 6 July 1999. She was his first girlfriend. Victoria was abused by both Kouao and Manning, and it is suspected that the abuse got worse from then on.
On 18 June 1999, a woman related to Kouao anonymously telephoned Brent council and told a customer services officer about Victoria's injuries and said that she feared for the girl's life. She rang again a few days later, and was given the impression they were onto the case. Three weeks later on 14 July 1999, social workers from the council visited Victoria's address, but it was empty and no further action was taken. In the inquiry following Victoria's death, Edward Armstrong, a senior social worker at the council, said that the team were told that a child was not in school, and not that a child was being abused.
On 13 July 1999, Kouao took Victoria to Cameron's house, saying that Manning did not want Victoria, and asking them to keep her permanently. They refused but agreed to take her for the night. When they saw her injuries, they took her to Central Middlesex Hospital, on 14 July 1999. The doctors alerted Brent police and social services, and she was placed under police protection, with a 72-hour protection order preventing her from leaving hospital. Kouao told the doctors that she had scabies, and that the injuries were self-inflicted. Many doctors and nurses suspected that the injuries were non-accidental. However, Ruby Schwartz, the consultant paediatrician and named child protection doctor at the hospital, diagnosed scabies and decided that it was scratching that caused the injuries. She made the diagnosis without speaking to Victoria alone. Schwartz later admitted that she made a mistake. Another doctor, one of Schwartz' juniors, misleadingly wrote to social services saying there was no child protection issue. When Michelle Hine, a child protection officer at Brent council, received a report notifying her of Victoria's injuries, she planned to open an investigation into the case. However, the next day she heard of Schwartz' diagnosis and downgraded Victoria's level of care, trusting Schwartz' judgement. She later expressed regret over her actions. Schwartz said in the inquiry that she expected social services to follow up the case. Neil Garnham QC, counsel to the inquiry following Victoria's death, later said to her, "there is a terrible danger here – is there not, doctor – of social services on the one hand and you on the other each expecting the other to do the investigation, with the result that nobody does". A police officer from Brent council, Rachel Dewar, decided to lift the police protection, allowing Victoria to return home, when told by a social worker that she had scabies. Under the Children Act 1989, Dewar was obliged to see Victoria and tell her she was under police protection, but she did not do this. She also failed to see Kouao or Manning. At the time of the decision, Dewar was attending a seminar on child protection. Garnham later said, "we will need to ask why it was thought more important for her to attend a seminar to learn how to deal with child protection cases than deal with the real child protection case for which she was responsible at the time". Kouao took Victoria home on 15 July 1999.
"Some time in July, probably just before Victoria was admitted to the Central Middlesex Hospital", Kouao befriended a couple, Julien and Chantal Kimbidima. Victoria and Kouao visited their home several times over the following months. According to Chantal, Kouao would shout at Victoria all the time and never showed her affection.
On 24 July 1999, Victoria was taken by Kouao to the accident-and-emergency department at North Middlesex Hospital with severe scalding to her head and other injuries. The hospital found no evidence of scabies. Consultant Mary Rossiter felt Victoria was being abused but still wrote 'able to discharge' on her notes. According to Maureen Ann Meates, another doctor at the hospital, when Rossiter had written that note, she had noted that Victoria was exhibiting signs of neglect, emotional abuse and physical abuse. Later, in the inquiry, Rossiter said that by writing 'able to discharge', she did not mean she wanted Victoria to go home, merely that she was physically fit to leave. Garnham said, "quite how the subtlety of that distinction was to be ascertained from the notes is far from obvious". Rossiter admitted to the inquiry that she had expected police and social services to follow up on the case. For a brief period while she was in hospital, Enfield social services took up the case before passing it to Haringey.
A social worker and police officer from Haringey council, Lisa Arthurworrey and Karen Jones, respectively, were assigned to her case, and were scheduled to make a home visit on 4 August 1999; however, the visit was cancelled once they heard about the scabies. Jones later said, "it might not be logical but I did not know anything about scabies". She said that she telephoned North Middlesex Hospital for information about the disease, but Garnham had evidence that the staff there dealt with no such inquiry. Jones was told by a doctor that Victoria's injuries were consistent with belt buckle marks, although she claimed in the inquiry there was no evidence of child abuse.
On 5 August 1999, a Haringey social worker, Barry Almeida, took Victoria to a National Society for the Prevention of Cruelty to Children (NSPCC) centre in Tottenham, where she was assigned to Sylvia Henry. There was some confusion as to why the centre was being referred to for the case. Henry later contacted Almeida and was told, according to Henry, that Victoria had moved out of the borough, thereby closing the case. Almeida said he could not remember whether this conversation did take place. On the same day, Kouao met Arthurworrey and Jones at the Haringey social services department, and claimed that Victoria had poured boiling water over herself to stop the itching caused by the scabies and that she had used utensils to cause the other injuries. The social worker and police officer believed her, deciding that the injuries were probably accidental, and allowed Climbié to return home the following day, which she did.
On 7 August 1999, Kouao visited Ealing social services; they said it was a housing issue and that the case was closed. Ealing social services would later be described as 'chaotic'. As a follow up measure, a staff member at the hospital contacted a health visitor, but the health visitor said in the inquiry that she did not receive any contact. On 13 August 1999, Rossiter wrote to Petra Kitchman of Brent council, asking her to follow up on the Victoria case. Kitchman said in the inquiry that she contacted Arthurworrey, but Arthurworrey denied this. Later, on 2 September 1999, Rossiter sent a second letter. Kitchman said she spoke to Arthurworrey about this, but Arthurworrey denied this again. Arthurworrey made a visit to Victoria's home on 16 August 1999 and another one when Manning began forcing Victoria to sleep in the bath. Arthurworrey said in the inquiry that she was under the impression that Victoria seemed happy, but Garnham criticised Arthurworrey for not detecting any of the abuse, although Manning had described this visit as a "put up job". Arthurworrey and Victoria had met on four occasions, where they were together for a total of less than 30 minutes, barely speaking to each other.
From then on, Kouao kept Victoria away from hospitals, turning instead to churches. Kouao said to the pastors that she was the mother and that demons were inside Victoria. The pastor at the Mission Ensemble Pour Christ, Pascal Orome, offered prayers for Victoria to cast out the devil, and thought that her injuries were due to demonic possession. On another occasion, Kouao took Victoria to a church run by the Universal Church of the Kingdom of God, where the pastor, Alvaro Lima, suspected she was being abused, although he took no action. He said in the inquiry that Victoria told him that Satan had told her to burn herself. The pastor did not believe her, but he still believed that a person could be possessed.
From October 1999 to January 2000, Manning forced Victoria to sleep in a bin liner in the bath in her own excrement. During a later police interview, Manning said this was because of her frequent bedwetting. At Haringey social services on 1 November 1999, Kouao told social workers that Manning sexually assaulted Victoria, but withdrew the accusation the following day. In one of Arthurworrey's visits, during a conversation about housing, Arthurworrey said that the council only accommodated children believed to be at serious risk. Laming said in his report, "it may be no coincidence that within three days of this conversation, Kouao contacted Ms. Arthurworrey to make allegations which, if true, would have placed Victoria squarely within that category". Jones sent a letter to Kouao, which was ignored, and no further action was taken. Manning later denied the allegation. Alan Hodges, the police sergeant overseeing the investigation, claimed in the inquiry that the social workers were obstructing the police in dealing with child protection cases. Between December 1999 and January 2000, Arthurworrey made three visits to the flat, but she received no answer. She speculated to her supervisor, Carole Baptiste, that they had returned to France. Despite no evidence, her supervisor wrote on Victoria's file that they had left the area. On 18 February 2000 they wrote to Kouao saying that if they did not receive any contact from them, they would close the case. A week later, on 25 February 2000, they closed the case – on the same day that Victoria died.
On 24 February 2000, Victoria was taken semi-conscious and suffering from hypothermia, multiple organ failure and malnutrition, to the local Universal Church of the Kingdom of God church. After they left the mini cab driver was horrified at Victoria's condition and took her straight to the accident-and-emergency department at North Middlesex Hospital; she was then transferred to the intensive-care unit at St Mary's Hospital. The ambulance driver who drove her to St Mary's described how although Kouao had kept saying, "my baby, my baby", her concern seemed "not quite enough", and that Manning seemed "almost as if he was not there". Victoria died the following day at 3:15pm local time – on the same day the Universal Church of the Kingdom of God church was planning to hold a service of deliverance for her to cast out the devil. The Home Office pathologist who examined her body noted 128 separate injuries and scars on her body, and described it as "the worst case of child abuse I've encountered". She had been burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires; and was known to four local authorities (four social services departments and three housing departments), two child protection police teams, two hospitals, an NSPCC centre, and a few local churches. She was buried in Grand-Bassam near her home town.
Kouao was arrested on the day that Victoria died, and Manning the following day. She told police, "It is terrible, I have just lost my child". On 20 November 2000 at the Old Bailey, the trial into her death opened, with Kouao and Manning being charged with child cruelty and murder. Kouao denied all charges, and Manning pleaded guilty to charges of cruelty and manslaughter. The judge described the teams in Victoria's case as "blindingly incompetent". During police interviews, both claimed that Victoria was possessed. In his diary, Manning described Victoria as Satan, and said that no matter how hard he hit her, she did not cry or show signs that she was hurt. On 12 January 2001, both were found guilty and sentenced to life imprisonment. The judge said to them, "what Anna endured was truly unimaginable. She died at both your hands, a lonely drawn out death". Kouao went to Durham prison and Manning went to Wakefield prison.
On 20 April 2000, the then–health secretary, Alan Milburn, and the then–home secretary, Jack Straw, called for an inquiry into her death. The inquiry, announced in April 2001 and launched on 31 May 2001, was chaired by William Laming, former chief inspector of the social services inspectorate (SSI). Laming was given the choice of staging a public inquiry or a private inquiry; he chose a public inquiry. This was the first public inquiry to be set up by two secretaries of state. The inquiry (actually three inquiries together called The Victoria Climbié Inquiry) has a statutory base of three pieces of legislation: section 81 of the Children Act 1989, section 84 of the National Health Service Act 1977, and section 49 of the Police Act 1996, drawing together the involvement of social services, the National Health Service, and the police; and becoming the first 'tripartite' inquiry into child protection. The Counsel to the Inquiry was Neil Garnham QC. The inquiry offices were based in Hannibal House, Elephant and Castle, London. The inquiry cost £3.8m, making it the most expensive child protection investigation in British history. A website, www.victoria-climbie-inquiry.org.uk, was created, where all the evidence and documents were made available freely.
The inquiry was split into two phases: phase one and phase two. Phase one investigated the involvement of people and agencies in Victoria's death, in the form of hearings. Two hundred and seventy witnesses were involved. The phase one hearings began on 26 September 2001 and finished on 31 July 2002; it was originally supposed to end on 4 February 2002 but late documents caused delays. Phase two of the inquiry, taking place between 15 March 2002 and 26 April 2002, took the form of five seminars, which looked at the child protection system in general. It was chaired by Garnham and brought together experts in all aspects of child protection.
The inquiry heard that many of the councils were under-staffed, under-funded, and poorly managed. The chief executive of Brent council said its social services department was "seriously defective". The inquiry was told that many cases at Brent social services were closed inappropriately before inspection by the social services inspectorate, that children were being placed unaccompanied in bed-and-breakfast accommodation, and that children in need were turned away. The inquiry heard how Edward Armstrong had previously been ordered not to work with children over his handling of a case in 1993. Haringey and Brent council diverted £18.7m and over £26m, respectively, in the two years 1997/98 and 1998/99, from its social services department into services such as education, for the purpose of gaining votes; both underspent their budgets for children's services, totalling £28m, by more than £10m in 1998–99, causing a deteriorating of child protection services. The inquiry heard how Haringey council failed to assign social workers to 109 children in May 1999, a short period before they took on Victoria's case. Again in January 2002, Haringey council failed to assign social workers to about 50 children. Haringey council wrote a letter to Laming claiming that social workers who gave evidence were being questioned more harshly than other witnesses. Laming condemned the letter, saying "I will not tolerate any covert attempt to influence the way in which the inquiry is conducted. Mary Richardson, the director of social services at Haringey from 1 April 1998 until 31 March 2000, had been responsible for a restructuring of the department which, according to the union Unison, had "virtually paralysed" the child protection service. She received contact from twelve senior practitioners and team managers criticising the proposals as "potentially dangerous and detrimental to the people to whom we offer a service". Richardson provided no substantive response to the memorandum. She did, however, say in the inquiry that the blame lay on "part of all of the line management responsibility". In April 2000, she became head of Hackney's social services department, with a salary of £100,000. Gurbux Singh, the former chief executive of Haringey council (before becoming the chairman of the Commission for Racial Equality), said that there was nothing he could have done to prevent Victoria's death. Garnham contrasted this with Rossiter's willingness to accept responsibility, saying, "that willingness to acknowledge error is at least at the root, is it not, of progress?
Kouao herself was called to the inquiry, becoming the first convicted murderer to appear in person in a public inquiry. She initially refused to answer questions, and when she did, protested her innocence, first in French, then, raising her voice in anger, in English. Giving evidence by video link from prison, Manning apologised for his actions and said that it was not the fault of the various agencies that Victoria died. Broadcasters applied for access to this video, but Laming refused the application. Victoria's parents gave evidence and were present at most of the hearings, becoming distressed when hearing of Victoria's plight and seeing pictures of her injuries. They blamed Haringey council and its chief executive for Victoria's death.
Arthurworrey, a junior worker with only nineteen months of child protection experience when she took on Victoria's case, was found to have made mistakes in the case. She accused her employer of "making her a scapegoat", and criticised her superiors and department for not guiding her properly. The inquiry heard that Arthurworrey was overworked, taking on more cases than guidelines allow. Carole Baptiste, Arthurworrey's first supervisor, initially refused to attend the hearings, but subsequently gave vague responses to the inquiry, and said that she had been suffering from mental illness at the time. Baptiste's own child was taken into care a few months before Victoria's death. Arthurworrey said that, in their meetings, Baptiste spent most of the time discussing "her experiences as a black woman and her relationship with God", rather than child protection cases, and that she was frequently absent. Baptiste admitted she had not read Victoria's file properly. She was removed in November 1999 when she was found to be professionally unfit for her job, and replaced by Angella Mairs, who became Arthurworrey's new supervisor. Mairs was accused by Arthurworrey of not maintaining childcare standards and of removing an important document – which recommended that Victoria's case be closed – from Victoria's file on 28 February 2000, the day the news of the death was known; but she denied this. Mairs said that she had not read Victoria's file.
The inquiry heard how the number of child protection police officers in the Metropolitan Police Service were reduced to increase the number of murder investigation officers, due to the recent Stephen Lawrence case. A detective inspector supervising six child protection teams in London at the time of Victoria's death wrote a report criticising their competence. His former boss, however, claimed he had been lying when he said he only held "purely administrative" responsibility for the teams. The detective inspector was taken to hospital when a woman poured ink over his head while testifying. The new chief executive of Haringey council, David Warwick, Baptiste, the Metropolitan Police, and the NSPCC apologised for their failings in the case.
The 400-page report, which made 108 recommendations in child protection reform, led to the formation of the Every Child Matters programme, a framework to improve the lives of children; the introduction of the Children Act 2004, an Act of Parliament that provides the legislative base for many of the reforms; the creation of ContactPoint, a database that will hold information on all children in England and Wales; and the creation of the post of children's commissioner, who heads the Office of the Children's Commissioner, a national agency serving children and families. Regional and local committees for children and families are to be set up, with members from all groups involved in child protection. Previously each local authority managed their own child protection register, a list of children believed to be at risk, and no national register existed; this, combined with local authorities' tendency to suppress information about child abuse cases, led to the implementation of the child database. The child protection register will be abolished and replaced by the database in 2008. Two organisations to improve the care of children, the General Social Care Council and the Social Care Institute for Excellence, had already been set up by the time the report was published.
In August 2002, Baptiste was fined £500 after being found guilty of deliberately failing to attend the inquiry. Victoria's parents, speaking through a family friend, said, "we, the family, expected her to be dealt with more severely". This was the first time a person had been prosecuted for not attending a public enquiry. In September 2002, Arthurworrey and Mairs were sacked following disciplinary procedures. The then–education secretary, Charles Clarke, also added them to the Protection of Children Act 1999 List, banning them from working with children. In October 2004, Arthurworrey appealed against her dismissal, saying that she was duped by Kouao and Manning, misled by medical reports, badly advised by her managers, and that she was a scapegoat for other people's failures, but the appeal was rejected. In 2005, she appealed the ban preventing her from working with children and won. In 2004, Mairs appealed her ban preventing her from working from children and won; this decision was challenged in the High Court but she prevailed. In 2004, six police officers involved in the case faced misconduct charges. All six kept their job, and some received reprimands and cautions. In 2004, the General Medical Council dropped misconduct charges against Dr. Schwartz.
Haringey council held a debate in the council chambers to discuss the Laming report. The parents of Victoria Climbié were invited to speak at the council by Councillor Ron Aitken, but the Council leader George Meehan denied then permission. Only pressure from the opposition and local press got the decision reversed. As George Meehan only reversed his decision just before the meeting, a driver was rushed to Acton to escort Francis and Berthe Climbié and Mor Dioum, their interpreter, to the council. At the meeting, Victoria Climbié's parents attacked the council, through their interpreter, for its handling of the case, especially in its dealing with the Laming Inquiry. (Mor Dioum later went on to be the Director of the Victoria Climbié Foundation)
The government placed Haringey social services department under special measures, requiring close supervision by the social services inspectorate. Allegations emerged that in 2004 and 2005, senior managers at Haringey council ignored child abuse cases and "became hostile" against a social worker who sought to expose the abuse.
Victoria's parents created the Victoria Climbié Foundation UK, a charity that seeks to improve child protection policies, and the Victoria Climbié Charitable Trust, an organisation to build a school in the Ivory Coast. Funding for the school has been raised, construction has started and will be completed by November 2007. Victoria's parents are also involved in championing many child protection reforms. A playwright, Lance Nielsen, wrote a play based on the events, staged at the Hackney Empire throughout 2002.
After Victoria's death, commentators discussed the history of child protection and the various abuse and death cases, noting that there have been 70 public inquiries into child abuse since 1945, and comparing Victoria's case with that of many others, especially that of Maria Colwell in 1973. They pointed to the many children abused and killed by their guardians over the years and how the agencies involved in their care let them down. They noted similarly that their deaths also led to inquiries and reform policies – reforms that have not saved the many children killed following them. They pointed out that, "an average of 78 children are killed by parents or minders every year; a figure unaltered in the 30 years since Maria Colwell's death provoked the first criticism of 'communications failure'". They expressed cynicism towards the possibility that these reforms would be different. Dr. Chris Harvey, director of operations at Barnardo's, for example, said, "Victoria's tragic case is the latest in a sad roll-call of child deaths, each leading to fresh inquiries and a new but recurring set of recommendations". Ian Willmore, former deputy leader of Haringey council, said, "the "script" for this kind of Inquiry is now almost traditional. The Minister goes on TV to insist that: "this must never happen again". Responsibility is pinned on a few expendable front-line staff, all conveniently sacked in advance. Criticisms are made about poor communication, with earnest recommendations about better co-ordination and possible restructuring. Council officers - all new appointments - go on TV to say that everything has changed since the case began. Everyone looks very earnest. Voices crack with compassion. Nothing essential changes".