After Victoria: Learning from experience and research

held in Birmingam on Wednesday 9 April 2003

report written by Sal Lodge, Development Officer, research in practice

introduction

This symposium set out to explore the many lessons to be drawn from i) the circumstances surrounding the death of Victoria Climbié and ii) the conclusions of the Government Inquiry.

The symposium included contributions from policy makers and research and considered how necessary safeguards for vulnerable children could be improved.

speakers

Andrew Cozens , Director of Social Services for Leicester City Council, spoke about the future shape of children and family services and what this might mean for social work as a profession. He also considered the links between child protection and family support.

John Fitzgerald , formerly founder and the Chief Executive of the Bridge Childcare Development Service, gave an overview which compared the Climbié Inquiry Report with some of the hundreds that have gone before. He also reflected on the politics of Inquiries in general.

Ashok Chand , University of Nottingham, School of Social Work, explored what it means to work with ethnic minority families and the lessons learned from the Climbié Inquiry Report.

Judith Laurance works as an independent consultant and trainer in the social care field and works primarily in post-qualifying social work education. She considered how the new Social Work Degree and the Post-Qualifying award could contribute to ensuring safe practice for children and families.

presentation 1 - Andrew Cozens
The Future Shape of Children and Family Services

Andrew Cozens presented his thoughts on the future shape of national Children and Family Services in the light of Lord Laming's report on the Victoria Climbié inquiry.

He began by asking delegates to reflect on the 55 different names and configurations (to date) for social services departments across the country - Housing and Social Services, Social Care and Housing, Environmental and Social Services, Community Based services, Social Well Being and Housing etc. He posed the question "Where would you look for social services in the phone book?" and showed how these different arrangements reflected the structural changes and the movement towards more integrated services for Children and Families.

We were challenged to consider how social exclusion for some children on the borders of 'need' could be avoided and how all children should be included in the provision of services following the Climbié report. All children require good universal services to promote their health and development through childhood. Vulnerable children, whose life chances will be jeopardised unless action is taken to prevent difficulties continuing, and Children in Need under Part 111 of the Children Act require services. All children on the Child Protection Register and all Children Looked After are Children in Need and also require appropriate services

The speaker presented the Cabinet Office's vision of desired outcomes for children and young people at risk. This vision embodies a co-ordinated service delivery that focuses on the child and concentrates mainstream services on prevention, learning from experience and improving services. This framework would require access for all Children in Need to universal services, where some vulnerable children may require provision from the local authority for a limited period - such as Sure Start schemes and Connexions - where services for children are generally accessed through an assessment process and through the use of threshold criteria. Children would move within this framework as their needs and circumstances change - often quite rapidly. Children who are both vulnerable and in need are likely to be in receipt of services, provided by a range of providers. These may be time limited, however, or be provided sequentially or concurrently, creating a complex configuration of services.

Local authorities play an important role here by providing appropriate departmental and business unit structures and associated systems, to deliver high quality, timely, locally accessible and responsive services. These services should ensure effective user participation and empowerment; they should remove unnecessary professional boundaries and achieve the most economic and effective use of available resources through integrated partnerships and strategic alliances.

In the wider service policy context - and bearing in mind the key partnerships and alliances that already exist and will be formed in the future - Lord Laming offers a challenge:

'I strongly believe that in the future those who occupy positions in the public sector must be required to account for any failure to protect vulnerable children from deliberate harm .' and 'The single most important change in the future must be the drawing of a clear line of accountability, from top to bottom, without doubt or ambiguity about who is responsible at every level for the well being of vulnerable children.' (Lord Laming, January 2003)

We were presented with several options to think about for new structural arrangements:

• Large scale merger, as they have done in Hertfordshire, where all children's services have merged with the Education Department under the direction of a Strategic Director for Children's Services.
  
• Strategic Merger which retains both Departments; adult and family services and some units are merged with Education
  
• A new dedicated department, i.e. where vulnerable children and children in need are a new department.
  
• Children's Trust where there is a pooled budget and where there is a transfer of some Education and Children's services units into a Trust alongside key health provision.
  
• A virtual organisation along the lines of the Youth Offending Team with a fully integrated service reporting to a partnership board drawing in other non-statutory services, and with a pooled budget.

Cozens argued that if we were to decide not to embark on new structures, then we would need to improve many aspects of work with children and families. For example, children and carer involvement would need improving and there would need to be an agreed common framework of services, standards and effective strategies and operational partnerships. Common assessment frameworks and joint working arrangements must reduce unnecessary and replicated assessments. There should be joint protocols in relation to joint working or common interests, and more flexible professional boundaries must be encouraged through training.

All this is needed and money too. There must be investment to change services. There are significant recruitment and retention and morale problems. Services for vulnerable children are subject to frequent legislative change, new initiatives, inspection and regulation. ICT is underdeveloped and management information is patchy. Costs of interventions are spiralling. Investment to change and to improve is needed, not just targeted investment for change in prescribed areas.

The speaker ended with an exhortation from Lord Laming for us to find

'a common language for use across all agencies to help those agencies to identify who they are concerned about, why they are concerned, who is best placed to respond to these concerns, and what outcome is being sought from any planned response.' (Lord Laming, Recommendation 13)

presentation 2 - John Fitzgerald
Post Climbié: What's New?

John Fitzgerald presented an overview of the conclusions from the Climbié Inquiry Report, and compared those conclusions with other Inquiries that have gone before.

He drew our attention to the fact that anyone reading the media coverage of the Climbié Inquiry, and who knew little of the subject, could be forgiven for thinking that what happened to Victoria was a one-off situation, or that the Inquiry was making recommendations to ensure such a tragedy would never happen again.

We were asked to consider the first formal child death Inquiry that was fifty years ago in the mid 1940s, known as the Curtis Committee Report. This was a case of extreme cruelty where Dennis O'Neill was tortured, neglected and subsequently died in his foster home. There was a failure on the part of those involved with the family to share information and a failure to visit and talk to the child. There was a complete lack of accountability throughout.

The Maria Colwell case in the early 1970s was the next inquiry that John Fitzgerald drew our attention to. This inquiry showed that Maria's death was deemed to be due to a complete lack of coherent decision-making throughout the time she was in contact with Social Services. There was a lack of information sharing, and a lack of inter-agency communication and consequently a lack of any collation of historical information. No adequate assessments of risk or need were carried out and there was a failure to involve the child, or place the child at the centre of decision-making.

The outcome of this Inquiry was the establishment of local authority child protection units and Area Child Protection Committees.

To date there have been forty such inquiries since. Since the Children Act (1989) more than 1,500 serious case reviews (Part 8 Case Reviews) have been carried out in the UK.

In 2002 a DoH funded study called 'Learning from Past Experiences' highlighted the 6 most common practice shortcomings:

• Inadequate sharing of information
  
• Poor assessment processes
  
• Ineffective decision-making
  
• Lack of interagency working
  
• Poor recording of information
  
• Lack of information on significant males

The Bridge Child Care Development Service has carried out over 43 Serious Case Reviews. An analysis of those reviews shows the same key practice failures (as above) plus:

• a failure to understand the significance of the history of the case
  
• over reliance by professionals on memory rather than actual facts
  
• antiquated recording systems
  
• lack of time and resources
  
• children who die very rarely have their names placed on the Child Protection registers but if they do it will be for a very short time and
  
• the children who die are hardly ever within the Child Protection system
  
• failure to take account of the views of children

All the failures listed above are at the centre of the Climbié Report and John Fitzgerald asserted that the recommendations by Lord Laming echo those of the hundreds of reports that have gone before them.

John Fitzgerald's practice recommendations:

• Stop thinking 're-organisation and re-structure'.
  
• Start asking the question - 'why do some carers kill?' More research is needed in this area but we should use the research we have already.
  
• Each child death should be subject to a serious case review and this has not always been the case.
  
• Be less naïve as professionals about families.
  
• Face up to the fact that not all professionals from different disciplines work well together.
  
• Stop paying lip service to the concept of listening to children and make it a reality. They have a right to be heard.

references:

The Victoria Climbié Inquiry Report (2003) The Stationery Office

Curtis Committee (1946) Care of Children Inquiry Report

Colwell Report (1973) HMSO

Bullock R and Sinclair R (2002) Learning from Past Experience . Department of Health

Heather and Charmaine West, Serious (Part 8) Case Review (1996) Gloucestershire ACPC

Fitzgerald J (1999) Child Protection and the Computer Age . The Bridge Publishing House Ltd.

Hagell A (1998) A Dangerous Care: Reviewing the risk to children from their carers . Policy Studies Institute

Jeyarajah Dent R (1998) Dangerous Care: Working to protect children . The Bridge Publishing House Ltd.

Falkov A (1996) A Study of Working Together Part 8 Reports: Fatal child abuse and psychiatric disorder . Department of Health

Reder P and Duncan S (1993) Beyond Blame: Child abuse tragedies revisited . Routledge

presentation 3 - Ashok Chand
Working with ethnic minority families: Lessons from Climbié

Ashok Chand outlined the complexities, assumptions and practices when working with ethnic minority children and families, and expressed dismay that these issues only come to the forefront when a child dies. However the Climbié Inquiry Report offers a critical review of social work practice, he did not think that racism was properly examined in the Inquiry or that the impact ethnicity had, on people working with Victoria, was adequately explored. His case is set out below with practice recommendations following each point.

Working with families who are not habitually resident in the UK. The attention Victoria had in Ealing was inadequate. There was no guidance for social workers for people presenting from abroad. These people are still entitled to support yet Victoria and her 'aunt' remained homeless. Families from abroad are perceived as a burden. The term 'not habitually resident' has financial implications and, in Victoria's case, was viewed very negatively by the manager involved. This particular discourse went unnoticed in the report.

recommendation: Social Services should have insisted that Victoria had a professional child-minder. After nine weeks in Ealing, all social workers did for Victoria was 'say hello'. Victoria's case was dealt with on an administrative basis only.

Assumptions about Black workers for Black families
Various research studies have shown that ethnically matching social workers with families does not necessarily mean better outcomes. Victoria was allocated a social worker who clearly did not have the necessary experience.

recommendation: The responsibility for working with minority ethnic families is everybody's responsibility, not just those from similar ethnic backgrounds.

Using interpreters with ethnic minority families
An interpreter and a social worker did an assessment in Victoria's case. Victoria's 'aunt' Kuao would not speak English. The English language failed Kuao in the questions about child protection during her assessment. In some languages the term or concept of 'sexual abuse' does not exist. Parents can sometimes seek an alliance with the interpreter and manipulate the situation. A study by Farmer and Owen, considering child protection, ethnicity and translation, found that no professional could be sure that complex meanings and terms were being accurately and sensitively relayed to the family

recommendation: These studies found that social workers felt that training about interpretation was needed. The question has to be asked as to whether there are genuine translation difficulties or is the situation being deliberately manipulated? All statutory organisations should develop sound interpretation and translation services.

Challenging minority ethnic families - fears and assumptions

As professionals, how do we arrive at our interpretations of a situation? Underlying Victoria's fate was a significant misinterpretation of her situation. The social worker described Victoria 'standing to attention' next to her aunt, and regarded this as Victoria showing respect. When Victoria was taken to hospital, staff were suspicious of her injuries but concluded that she had scabies. This was based on the assumption that she had lived in 'poor conditions in Africa.'

There was significant reference in the report as to how social workers failed to challenge the fact that Victoria's 'aunt' was not her mother. Inconsistencies in her history were not challenged. Professionals seemed unwilling to ask sensitive questions regarding skin colour for instance. In this case it appeared that professional practice was affected by the fear of being accused of racism. This fear can stop people acting.

recommendation: Anti-oppressive practice must be included in social work training on assessing parents from ethnic minority groups. All social workers must be prepared to work with people from diverse backgrounds and must work on dispelling their own prejudices and stereotypes.
Chand suggested that every statutory organisation has a responsibility to ensure that all their staff are trained to be confident and competent when working with minority ethnic children and families.

Structural problems in local authorities and the impact for ethnic minority families

There were evidently inter-agency tensions between different organisations in the Climbié case as well as intra-agency tensions between staff and management. It was implied by a senior manager that some social workers were illiterate.

recommendation: Managers should ensure that written communication deficits in workers, where English may well be a second language, are met through proper training, supervision and professional development.

Improving practice with ethnic minority families

The concerns raised here concern specific aspects of child protection and ethnicity and indicate some of the very real complexities, assumptions and practices about working with families from minority ethnic groups

recommendation: All statutory organisations should establish a suitable inter-agency forum where discussion about policy and practice with minority ethnic families can be held.

references:

Baker P Hussain Z and Saunders J (1991) Interpreters in Public Services . Birmingham: Venture Press in association with Further Education Unit

Brophy J (2000) ''Race' and Ethnicity in Care Proceedings: Implications from a national survey of cases containing expert evidence' Adoption and Fostering , 24 (2) 70-2

Farmer E and Owen M (1995) Child Protection Practice: Private risks and public remedies . London: HMSO

Humphreys C Atkhar S and Baldwin N (1999) 'Discrimination in Child Protection Work: Recurring themes in work with Asian families', Child and Family Social Work 4

Click here to read Ashok Chand's article about this talk given at this research in practice Symposium - ''Race' and the Laming Report on Victoria Climbié: Lessons for Inter-Professional Policy and Practice', Journal of Integrated Care 11 (4) August 2003

presentation 4 - Judith Laurance
The Climbié Report: How can the Post-Qualifying award contribute to ensuring safe practice for children and families?

Jaqui Smith, in her foreword to the Department of Health 'Requirements for Social Work Training' said

'Social workers need to be able to deal with some of the most vulnerable people in our society at times of greatest stress. There can be tragic consequences if things go wrong .social workers need to be properly equipped for such challenging tasks.' (2002)

Judith Laurance rooted her talk about Social Work Training and the aims for the new Social Work Degree firmly in the context of social work. She acknowledged the current severe difficulties in recruiting and retaining child welfare and protection workers describing how applications for social work training fell by 59% between 1995 and 2002 and how many managers are afraid that the impact of the Laming Report will make recruitment even more problematic.

Whatever one's knowledge, experience and competence,

'...the complexity and long standing nature of child care problems makes them fiendishly difficult to deal with. Yet the main responsibility rests with those on the lowest rung of the hierarchy who usually lack the seniority and power to access key resources.' The Pink Book , DoH (1985)

Laurance maintained that first it was essential to have expectations about conditions of employment for social workers if trying to promote safe practice when working with children and families; that they should they have a clear job description, a sound induction and a protected case load in the early stages of their career, adequate training opportunities, regular supervision and support from peers, good administrative back up, a balance of cases (high/low stress) and opportunities for reflection and forward planning.

To ensure safe practice for children and families one should expect that staff have clear and accessible procedures and guidelines, an understanding of who does what in the organisation, adequate funding and resourcing, full staffing and low staff turnover, permanent positions, career development opportunities, sound equal opportunities policies and practice, and good communications within their organisations.

Or should we aspire to some "great expectations" as indicated by Lord Laming, that in order to work safely with children, management should be more in touch with the grassroots. There should be continuity of management and a stable organisational structure with good working relationships between local agencies where staff have regular hours and good time off, good physical surroundings, a reasonable salary, good health and safety conditions, and good IT and IT support. Would all this eliminate the risk factor in social work and avoid tragedies such as Victoria's?

The reality is social workers now work in a climate of 'naming, shaming and blaming'. (1992) In a world where they feel checked up on through audits, and where family support is seen as of secondary importance, where the main focus is on child protection, and the priority for child care social workers remains identification, assessment and management of risk. Social workers' training, working conditions, support and management must be taken into account when assessing risk in child protection work.

The nine research studies in the Pink Book (1985) show that social workers and their seniors are currently not offered the opportunity to acquire the above sophisticated skills, knowledge and qualitative experience to equip them to deal confidently with the complex and extremely emotive issues raised by work with children and families.

The Pink Book also states how there

'. is an overwhelming impression of social workers' passivity and their feelings of helplessness and being at the mercy of events and actions of other people and other agencies.'

The aspiration now is that the new Social Work Degree

' will put social work on an equal footing with similar professions, and the enhanced learning and status will help improve its image and attractiveness. It will bring in a new generation of people into social work and help ease some of the recruitment difficulties some employers are encountering' (Rodney Brooke, Chair of GSCC)

The new Social Work Degree will generate an environment of intellectual rigour combined with personal support, and it will help students to integrate first class learning with practice opportunities whilst ensuring that students learn the ability to use knowledge critically - including the capacity to weigh and analyse different kinds of evidence.

Why do we need the post qualifying Child Care Award (CCA) as well? With the CCA social workers are offered the opportunity for 'thoughtful learning' - to examine research evidence critically, to understand themselves and their mandate, and to take part in an honest dialogue with tutors, practitioners, peers and service users. Developing professional judgement and encouraging reflection allows social workers to "see the children" and understand the child's experience from their point of view. With the CCA practitioners are encouraged to see themselves as 'experts' who can integrate their practice wisdom with sound research informed evidence. It allows for debate and reflection on possible conflict between theory and practice. This is the difference post qualifying training can make.

The speaker highlighted some key issues which need to be addressed for Social Work education and training in relation to the Victoria Climbié inquiry. How can practitioners who act as mentors and assessors be properly supported trained and valued? What happens about 'failing' social workers? How will social work education cope with changes in the organisation of service delivery? How can we embed our understanding of diversity of the needs of different cultural and ethnic groups within social work education?

And critically, how do we enable managers and senior practitioners to keep abreast of sound research and developments in policy and practice? And how do we ensure that the supervision they offer meets the needs of social workers who are working with complex child care cases?

Working and learning across professional boundaries will go a long way towards acknowledging commonalities and respect for differences across agencies. Practitioners and service managers will need to understand the differences as well as the common goals, standards and procedures. It is essential that social workers are encouraged through their training to reflect upon and contribute to discussion about the changing roles of the profession in wider society.

references:

Pettigrew A (1985) The Awakening Giant: Continuity and change in I.C.I. Blackwell

Department of Health (1985) The Pink Book: Social Work Decisions in Child Care

Ulrich (1992) 'The Risk Society' in Towards a New Modernity . Sage

Department of Health (2002) Requirements for Social Work Training (Jaqui Smith, Minister of State)

practice agency Sessions:

Organisational Management issues arising from the Climbié Inquiry - Colin Green - Assistant Director of Children's Services, Cambridgeshire.

This workshop addressed the issues of why the child protection system fails by looking at a whole systems and managerial model of organisations. Colin Green argued the case that focus is needed on the wider organisational and systemic framework of agencies involved in delivering services to children.

Child Protection Assessment and Management of Severe Physical Abuse - Richard Green , Senior Consultant, NSPCC

This session looked at an original piece of research " What Really Happened? Child Protection Case Management of Infants With Serious Injuries and Parental Explanations (2002) " Peter Dale, Richard Green and Ron Fellows, on serious/fatal abuse. It examined the implications for policy and practice and considered the role of the ACPC in the light of the Climbié report.

BAAF's response to the Climbié Inquiry: the link with private fostering - Felicity Collier , Chief Executive, British Association for Adoption and Fostering

This workshop examined what we can learn from the Climbié Inquiry about why so many West African families allow their children to live with strangers, and what steps must now be taken to safeguard these children. In rejecting amendments to the Adoption and Children Act to introduce a registration scheme, the government indicated they were waiting for Lord Laming to report. We still await the outcome of the Department of Health's Review of Private Fostering announced in January 2002. What have we learnt since Bob Holman's seminal study 'Trading in children' in 1973 and why is it taking so long?

Focusing on Improvements - Kate Fletcher , Senior Nurse, Child Protection

This workshop offered a response from Health to the Laming Inquiry on how agencies can work together to meet the challenges posed by the Inquiry and explored best practice.

ACPCs, agency, interagency and community training - Steve Hayes , Child Protection Development Manager, Portsmouth City Council and Daphne Rose , Designated Nurse, South East Hampshire

This session looked at how Portsmouth County Council and partner agencies work within and across ACPCs to promote quality training on child protection issues and multi agency working.

Practical steps for improving child protection services - Josephine Kwhali , Head of Children and Families Services, Hackney and Collette Elliott , Service Manager (CP)

This workshop explored Hackney's view of how to bring greater managerial scrutiny to the child protection process - especially in challenging racially diverse and highly pressurised urban areas such as the ones in which Victoria lived and died.

conclusion

What are the implications for multi-agency working? How should current training and professional development be shaped to support practitioners in the field? What questions need to be addressed to develop culturally appropriate practice? Keynote speakers and practice agency led sessions considered all these questions and demonstrated examples of service development drawn from research messages which add to our evidence base for future services.