Victoria Climbie Inquiry

With the support of the Prime Minister, a ministerial Children and Families Board should be established at the heart of government. The Board should be chaired by a minister of Cabinet rank and should have ministerial representation from government departments concerned with the welfare of children and families.

The chief executive of a newly established National Agency for Children and Families will report to the ministerial Children and Families Board. The post of chief executive should incorporate the responsibilities of the post of a Children’s Commissioner for England.

The newly established National Agency for Children and Families should have the following responsibilities: • to assess, and advise the ministerial Children and Families Board about, the impact on children and families of proposed changes in policy; • to scrutinise new legislation and guidance issued for this purpose; • to advise on the implementation of the UN Convention on the Rights of the Child; • to advise on setting nationally agreed outcomes for children and how they might best be achieved and monitored; • to ensure that legislation and policy are implemented at a local level and are monitored through its regional office network; • to report annually to Parliament on the quality and effectiveness of services to children and families, in particular on the safety of children.

The National Agency for Children and Families will operate through a regional structure which will ensure that legislation and policy are being implemented at a local level, as well as providing central government with up-to-date and reliable information about the quality and effectiveness of local services.

The National Agency for Children and Families should, at their discretion, conduct serious case reviews (Part 8 reviews) or oversee the process if they decide to delegate this task to other agencies following the death or serious deliberate injury to a child known to the services. This task will be undertaken through the regional offices of the Agency with the authority vested in the National Agency for Children and Families to secure, scrutinise and analyse documents and to interview witnesses. I consider it advisable that these case reviews are published, and that additionally, on an annual basis, a report is produced collating the Part 8 review findings for that year.

Each local authority with social services responsibilities must establish a Committee of Members for Children and Families with lay members drawn from the management committees of each of the key services. This Committee must ensure the services to children and families are properly co-ordinated and that the inter-agency dimension of this work is being managed effectively.

The local authority chief executive should chair a Management Board for Services to Children and Families which will report to the Member Committee referred to above. The Management Board for Services to Children and Families must include senior officers from each of the key agencies. The Management Board must also establish strong links with community-based organisations that make significant contributions to local services for children and families. The Board must ensure staff working in the key agencies are appropriately trained and are able to demonstrate competence in their respective tasks. It will be responsible for the work currently undertaken by the Area Child Protection Committee.

The Management Board for Services to Children and Families must appoint a director responsible for ensuring that inter-agency arrangements are appropriate and effective, and for advising the Management Board for Services to Children and Families on the development of services to meet local need. Furthermore, each Management Board for Services to Children and Families should: • establish reliable ways of assessing the needs and circumstances of children in their area, with particular reference to the needs of children who may be at risk of deliberate harm; • identify ways of establishing consultation groups of both children and adult users of services.

The budget contributed by each of the local agencies in support of vulnerable children and families should be identified by the Management Board for Services to Children and Families so that staff and resources can be used in the most flexible and effective way.

As part of their work, the government inspectorates should inspect both the quality of the services delivered, and also the effectiveness of the inter-agency arrangements for the provision of services to children and families.

The Government should review the law regarding the registration of private foster carers.

Front-line staff in each of the agencies which regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded. This must include the child’s name, address, age, the name of the child’s primary carer, the child’s GP, and the name of the child’s school if the child is of school age. Gaps in this information should be passed on to the relevant authority in accordance with local arrangements.

The Department of Health should amalgamate the current Working Together and the National Assessment Framework documents into one simplified document. The document should tackle the following six aspects in a clear and practical way: • It must establish 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 those concerns, and what outcome is being sought from any planned response. • It must disseminate a best practice approach by social services to receiving and managing information about children at the ‘front door’. • It must make clear in cases that fall short of an immediately identifiable section 47 label that the seeking or refusal of parental permission must not restrict the initial information gathering and sharing. This should, if necessary, include talking to the child. • It must prescribe a clear step-by-step guide on how to manage a case through either a section 17 or a section 47 track, with built-in systems for case monitoring and review. • It must replace the child protection register with a more effective system. Case conferences should remain, but the focus must no longer be on whether to register or not. Instead, the focus should be on establishing an agreed plan to safeguard and promote the welfare of the particular child. • The new guidance should include some consistency in the application of both section 17 and section 47.

The National Agency for Children and Families should require each of the training bodies covering the services provided by doctors, nurses, teachers, police officers, officers working in housing departments, and social workers to demonstrate that effective joint working between each of these professional groups features in their national training programmes.

The newly created local Management Boards for Services to Children and Families should be required to ensure training on an inter-agency basis is provided. The effectiveness of this should be evaluated by the government inspectorates. Staff working in the relevant agencies should be required to demonstrate that their practice with respect to inter-agency working is up to date by successfully completing appropriate training courses.

The Government should issue guidance on the Data Protection Act 1998, the Human Rights Act 1998, and common law rules on confidentiality. The Government should issue guidance as and when these impact on the sharing of information between professional groups in circumstances where there are concerns about the welfare of children and families.

The Government should actively explore the benefit to children of setting up and operating a national children’s database on all children under the age of 16. A feasibility study should be a prelude to a pilot study to explore its usefulness in strengthening the safeguards for children.

When communication with a child is necessary for the purposes of safeguarding and promoting that child’s welfare, and the first language of that child is not English, an interpreter must be used. In cases where the use of an interpreter is dispensed with, the reasons for so doing must be recorded in the child’s notes/case file.

Managers of duty teams must devise and operate a system which enables them immediately to establish how many children have been referred to their team, what action is required to be taken for each child, who is responsible for taking that action, and when that action must be completed.

Directors of social services must ensure that staff in their children and families’ intake teams are experienced in working with children and families, and that they have received appropriate training.

When a professional makes a referral to social services concerning the well-being of a child, the fact of that referral must be confirmed in writing by the referrer within 48 hours.

If social services place a child in temporary accommodation, an assessment must be made of the suitability of that accommodation and the results of that assessment must be recorded on the child’s case file. If the accommodation is unsuitable, this should be reported to a senior officer.

If social services place a child in accommodation in another local authority area, they must notify that local authority’s social services department of the placement. Unless specifically agreed in writing at team manager level by both authorities or above, the placing authority must retain responsibility for the child concerned.

Where, during the course of an assessment, social services establish that a child of school age is not attending school, they must alert the education authorities and satisfy themselves that, in the interim, the child is subject to adequate daycare arrangements.

All social services assessments of children and families, and any action plans drawn up as a result, must be approved in writing by a manager. Before giving such approval, the manager must ensure that the child and the child’s carer have been seen and spoken to.

Directors of social services must ensure that no case involving a vulnerable child is closed until the child and the child’s carer have been seen and spoken to, and a plan for the ongoing promotion and safeguarding of the child’s welfare has been agreed.

Chief executives and lead members of local authorities with social services responsibilities must ensure that children’s services are explicitly included in their authority’s list of priorities and operational plans.

The Department of Health should require chief executives of local authorities with social services responsibilities to prepare a position statement on the true picture of the current strengths and weaknesses of their ‘front door’ duty systems for children and families. This must be accompanied by an action plan setting out the timescales for remedying any weaknesses identified.

Directors of social services must devise and implement a system which provides them with the following information about the work of the duty teams for which they are responsible: • number of children referred to the teams; • number of those children who have been assessed as requiring a service; • number of those children who have been provided with the service that they require; • number of children referred who have identified needs which have yet to be met.

Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes.

Directors of social services must ensure that all staff who work with children have received appropriate vocational training, receive a thorough induction in local procedures and are obliged to participate in regular continuing training so as to ensure that their practice is kept up to date.

Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or at least compatible with it, so as to facilitate the sharing of information, as appropriate.

Local authorities with responsibility for safeguarding children should establish and advertise a 24-hour free telephone referral number for use by members of the public who wish to report concerns about a child. A pilot study should be undertaken to evaluate the feasibility of electronically recording calls to such a number.

Social workers must not undertake home visits without being clear about the purpose of the visit, the information to be gathered during the course of it, and the steps to be taken if no one is at home. No visits should be undertaken without the social worker concerned checking the information known about the child by other child protection agencies. All visits must be written up on the case file.

Directors of social services must ensure that children who are the subject of allegations of deliberate harm are seen and spoken to within 24 hours of the allegation being communicated to social services. If this timescale is not met, the reason for the failure must be recorded on the case file.

No emergency action on a case concerning an allegation of deliberate harm to a child should be taken without first obtaining legal advice. Local authorities must ensure that such legal advice is available 24 hours a day.

The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child.

Directors of social services must ensure that the transfer of responsibility of a case between local authority social services departments is always recorded on the case file of each authority, and is confirmed in writing by the authority to which responsibility for the case has been transferred.

All front-line staff within local authorities must be trained to pass all calls about the safety of children through to the appropriate duty team without delay, having first recorded the name of the child, his or her address, and the nature of the concern. If the call cannot be put through immediately, further details from the referrer must be sought (including their name, address and contact number). The information must then be passed verbally and in writing to the duty team within the hour.

Directors of social services must ensure that no case that has been opened in response to allegations of deliberate harm to a child is closed until the following steps have been taken: • The child has been spoken to alone. • The child’s carers have been seen and spoken to. • The accommodation in which the child is to live has been visited. • The views of all the professionals involved have been sought and considered. • A plan for the promotion and safeguarding of the child’s welfare has been agreed.

Chief executives of local authorities with social services responsibilities must make arrangements for senior managers and councillors to regularly visit intake teams in their children’s services department, and to report their findings to the chief executive and social services committee.

Directors of social services must ensure that where the procedures of a social services department stipulate requirements for the transfer of a case between teams within the department, systems are in place to detect when such a transfer does not take place as required.

No social worker shall undertake section 47 inquiries unless he or she has been trained to do so. Directors of social services must undertake an audit of staff currently carrying out section 47 inquiries to identify gaps in training and experience. These must be addressed immediately.

When staff are temporarily promoted to fill vacancies, directors of social services must subject such arrangements to six-monthly reviews and record the outcome.

Directors of social services must ensure that the work of staff working directly with children is regularly supervised. This must include the supervisor reading, reviewing and signing the case file at regular intervals.

Directors of social services must ensure that the roles and responsibilities of child protection advisers (and those employed in similar posts) are clearly understood by all those working within children’s services.

The chief executive of each local authority with social services responsibilities must ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week. The safeguarding of children should not be part of the responsibilities of general out-of-office-hours teams.

Directors of social services must ensure that when children and families are referred to other agencies for additional services, that referral is only made with the agreement of the allocated social worker and/or their manager. The purpose of the referral must be recorded contemporaneously on the case file.

When a professional from another agency expresses concern to social services about their handling of a particular case, the file must be read and reviewed, the professional concerned must be met and spoken to, and the outcome of this discussion must be recorded on the case file.

Directors of social services must ensure that when staff are absent from work, systems are in place to ensure that post, emails and telephone contacts are checked and actioned as necessary.

Directors of social services must ensure that all strategy meetings and discussions involve the following three basic steps: • A list of action points must be drawn up, each with an agreed timescale and the identity of the person responsible for carrying it out. • A clear record of the discussion or meeting must be circulated to all those present and all those with responsibility for an action point. • A mechanism for reviewing completion of the agreed actions must be specified. The date upon which the first such review is to take place is to be agreed and documented.

Directors of social services must ensure that no case is allocated to a social worker unless and until his or her manager ensures that he or she has the necessary training, experience and time to deal with it properly.

When allocating a case to a social worker, the manager must ensure that the social worker is clear as to what has been allocated, what action is required and how that action will be reviewed and supervised.

Directors of social services must ensure that all cases of children assessed as needing a service have an allocated social worker. In cases where this proves to be impossible, arrangements must be made to maintain contact with the child. The number, nature and reasons for such unallocated cases must be reported to the social services committee on a monthly basis.

Directors of social services must ensure that only those cases in which a social worker is actively engaged in work with a child and the child’s family are deemed to be ‘allocated’.

Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by social services that the home environment is safe, the concerns of the medical staff have been fully addressed, and there is a social work plan in place for the ongoing promotion and safeguarding of that child’s welfare.

Directors of social services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries.

Directors of social services must ensure that every child’s case file includes, on the inside of the front cover, a properly maintained chronology.

Directors of social services must ensure that staff working with vulnerable children and families are provided with up-to-date procedures, protocols and guidance. Such practice guidance must be located in a single-source document. The work should be monitored so as to ensure procedures are followed.

Directors of social services must ensure that hospital social workers working with children and families are line managed by the children and families’ section of their social services department.

Directors of social services must ensure that hospital social workers participate in all hospital meetings concerned with the safeguarding of children.

Where hospital-based social work staff come into contact with children from other local authority areas, the directors of social services of their employing authorities must ensure that they work to a single set of guidance agreed by all the authorities concerned.

Hospital social workers must always respond promptly to any referral of suspected deliberate harm to a child. They must see and talk to the child, to the child’s carer and to those responsible for the care of the child in hospital, while avoiding the risk of appearing to coach the child.

When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.

When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child’s best interests. When that is so, the history should be taken even when the consent of the carer has not been obtained, with the reason for dispensing with consent recorded by the examining doctor. Working Together guidance should be amended accordingly. In those cases in which English is not the first language of the child concerned, the use of an interpreter should be considered.

When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.

When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been raised as an alternative diagnosis to a purely medical one, the diagnosis of deliberate harm must not be rejected without full discussion and, if necessary, obtaining a further opinion.

When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what it is they wish to have recorded on their behalf.

When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which case notes are not available to them, a record of all discussions must be entered in the case notes at the earliest opportunity so that this becomes part of the child’s permanent health record.

Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician above the grade of senior house officer. Hospital chief executives must introduce systems to monitor compliance with this recommendation.

Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. Hospital chief executives must introduce systems to monitor compliance with this recommendation.

No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been admitted.

When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be obtained from the other hospitals. The consultant in charge of the case must review this information when making decisions about the child’s future care and management. Hospital chief executives must introduce systems to ensure compliance with this recommendation.

Any child admitted to hospital about whom there are concerns about deliberate harm must receive a full and fully-documented physical examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise the child’s care or the child’s physical and emotional well-being.

In a case of possible deliberate harm to a child in hospital, when permission is required from the child’s carer for the investigation of such possible deliberate harm, or for the treatment of a child’s injuries, the permission must be sought by a doctor above the grade of senior house officer.

When a child is admitted to hospital with concerns about deliberate harm, a clear decision must be taken as to which consultant is to be responsible for the child protection aspects of the child’s care. The identity of that consultant must be clearly marked in the child’s notes so that all those involved in the child’s care are left in no doubt as to who is responsible for the case.

All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, these must be corrected at the earliest opportunity in writing. It is the responsibility of the doctor to ensure that his or her concerns are properly understood.

Within a given location, health professionals should work from a single set of records for each child.

During the course of a ward round, when assessing a child about whom there are concerns about deliberate harm, the doctor conducting the ward round should ensure that all available information is reviewed and taken account of before decisions on the future management of the child’s case are taken.

When a child for whom there are concerns about deliberate harm is admitted to hospital, a record must be made in the hospital notes of all face-to-face discussions (including medical and nursing ‘handover’) and telephone conversations relating to the care of the child, and of all decisions made during such conversations. In addition, a record must be made of who is responsible for carrying out any actions agreed during such conversations.

Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.

The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.

The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.

All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.

The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection investigation, to support the revalidation of doctors described in the preceding recommendation.

The Department of Health should invite the Royal College of General Practitioners to explore the feasibility of extending the process of new child patient registration to include gathering information on wider social and developmental issues likely to affect the welfare of the child, for example their living conditions and their school attendance.

The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general practice, and at regular intervals of no less than three years thereafter.

The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for whom contact with children is a regular feature of their work.

All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection concerns in relation to any of their patients.

Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and procedures must be subject to regular audit by primary care trusts.

Save in exceptional circumstances, no child is to be taken into police protection until he or she has been seen and an assessment of his or her circumstances has been undertaken.

Chief constables must ensure that crimes involving a child victim are dealt with promptly and efficiently, and to the same standard as equivalent crimes against adults.

Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.

In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.

The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.

Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts as the designated officer in all cases.

Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing must be eradicated.

The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.

The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This will remove any confusion about which agency takes the ‘lead’ or is responsible for certain actions.

Training for child protection officers must equip them with the confidence to question the views of professionals in other agencies, including doctors, no matter how eminent those professionals appear to be.

The Home Office, through Her Majesty’s Inspectorate of Constabulary, must take a more active role in maintaining high standards of child protection investigation by means of its regular Basic Commands Unit and force inspections. In addition, a follow-up to the Child Protection thematic inspection of 1999 should be conducted.

The Home Office, through Centrex and the Association of Chief Police Officers, must devise and implement a national training curriculum for child protection officers as recommended in 1999 by Her Majesty’s Inspectorate of Constabulary in its thematic inspection report, Child Protection.

Chief constables must ensure that officers working on child protection teams are sufficiently well trained in criminal investigation, and that there is always a substantial core of fully trained detective officers on each team to deal with the most serious inquiries.

The Police Information Technology Organisation (PITO) should evaluate the child protection IT systems currently available, and make recommendations to chief constables, who must ensure their police force has in use an effective child-protection database and IT management system.

Chief constables must ensure that child protection teams are fully integrated into the structure of their forces and not disadvantaged in terms of accommodation, equipment or resources.

The Home Office must ensure that child protection policing is included in the list of ministerial priorities for the police.

Chief constables and police authorities must give child protection investigations a high priority in their policing plans, thereby ensuring consistently high standards of service by well-resourced, well-managed and well-motivated teams.

The Home Office, through Centrex, must add specific training relating to child protection policing to the syllabus for the strategic command course. This will ensure that all future chief officers in the police service have adequate knowledge and understanding of the roles of child protection teams.