UK Child Protection: Maria Colwell vs Victoria Climbié Inquiries, Lecture notes of Communication

Download UK Child Protection: Maria Colwell vs Victoria Climbié Inquiries and more Lecture notes Communication in PDF only on Docsity! 1 FROM MARIA COLWELL TO VICTORIA CLIMBIE: REFLECTIONS ON A GENERATION OF PUBLIC INQUIRIES INTO CHILD ABUSE Plenary paper by Professor Nigel Parton for the BASPCAN conference, July 2003 (published in Child Abuse Review (2004), 13 (2), pp80-94) In his statement to the House of Commons when presenting Lord Laming’s Inquiry Report into the death of Victoria Climbié, on 28 January 2003, the Secretary of State for Health, Alan Milburn, said: It is an all too familiar cry. In the past few decades there have been dozens of inquiries into awful cases of child abuse and neglect. Each has called on us to learn the lesson of what went wrong. Indeed, there is a remarkable consistency in both what went wrong and what is advocated to put it right. Lord Laming’s Report goes further. It recognises that the search for a simple solution or a quick fix will not do. It is not just national standards, or proper training, or adequate resources, or local leadership, or new structures that are needed. It is all of these things. (my emphasis) This theme, of the failure to learn the lessons of the many public inquiries over the previous thirty years, was a central one which was picked up in the ensuing House of Commons debate and in the media and press coverage of the publication of the report, both on 28 and 29 January 2003. It was as if the frontline professionals, and the key organisations and agencies who have responsibility for children and families were quite incapable of learning the lessons and, crucially, putting these into practice in such a way that such horrendous tragedies could be avoided. It is hoped by many, therefore, that the report by Lord Laming, and the changes brought about as a result, will mean that this will be the last report of its type. 2 In many respects, we can see the publication of this most recent child abuse inquiry report as the end of an era. It is now a generation since the publication of the first of these reports in 1974 into the care and supervision provided in relation to Maria Colwell, who had died in January of 1973. The intervening twenty-nine years have seen the publication of over seventy reports, which have not only been concerned with children who have died as a direct result of physical abuse and neglect, but have also included inquiries into abuse in residential and day care (Corby et al, 2001) and the apparent, over-intervention, of state agencies, the most infamous of which was that into the events of Cleveland in 1987 (Secretary of State, 1988). In this paper, I wish to reflect on some of the changes we can identify over this thirty year period. More particularly, I intend to compare and contrast the Maria Colwell and Victoria Climbié inquiries. In doing so, I am reading the reports as being emblematic of their respective times. I will be reading them as particularly high profile instances of the contexts in which they are located. As such, they can be seen to provide fascinating insights into the changes we have lived through over this thirty year period. As I will point out, there are very many similarities between the two reports and the respective cases and the way they were handled. However, my central argument is that rather than concentrate on the similarities it is important to consider and analyse the differences. It is my view that these differences are crucial, both in terms of understanding the changes in the nature of practice and the contexts within which it is located, but also in terms of what might be done in the future. While my primary purpose is analytic, I will, by way of conclusion, try and identify some key themes which I feel might be helpful in informing how we might think about, reframe and reform policy and practice in the future. 5 health and welfare systems available to children and families. It was the Maria Colwell inquiry that ushered in major practice changes following the DHSS circular in April 1974 and which in effect introduced the modern child protection system in this country, in terms of the establishment of what we now call Area Child Protection Committees, the institutionalisation of the case conference system and the establishment of child protection registers, as well as all the procedures which have been refined and updated over the subsequent thirty year period. Both inquiries seem to demonstrate failure and that ‘something needs to be done’. It is in this context that it is likely that the Laming Inquiry seems to be ushering in another major period of change. Finally, both inquiries were established by the relevant Secretary of State. However, this is perhaps the first important area of difference, for whereas the Maria Colwell inquiry was set up by the Secretary of State for Social Services, the Victoria Climbié inquiry was set up by the Secretary of State for Health together with the Secretary of State at the Home Office. In effect, the latter was to conduct three parallel statutory inquiries in relation to local authority social services, health services as well as the police. Similarly, its terms of reference were somewhat broader, for rather than only being concerned with the circumstances leading to and surrounding the death of Victoria Climbié, the Inquiry was also required to make recommendations as to ‘how such an event may, as far as possible, be avoided in the future’. The Victoria Climbié inquiry thus had a much wider brief. I now want to look more explicitly at some of the key differences, beginning with the inquiry reports themselves. 6 The Differences The Inquiry Reports While similar in many respects, there are also important differences in the two reports. These differences are indicative of the different times in which they are produced. The Maria Colwell inquiry report is much smaller in terms of the size of the pages and is 120 pages in length, consisting of approximately 50,000 words. It has a very official looking green cover to it, which was common for its time and has the Department of Health and Social Security, together with the official insignia on the cover, and is published by Her Majesty’s Stationery Office. It is entitled ‘Report of the Committee of Inquiry into the care and supervision provided in relation to Maria Colwell’. It is written by the inquiry team which consisted of three people, chaired by a QC, but has a minority report from one of its members, Olive Stevenson, who had a different interpretation of some of the key elements and decisions, particularly in the way the case was handled prior to Maria being placed on a supervision order and returned home to her mother and stepfather from foster care. In contrast, the Victoria Climbié inquiry report is over 400 pages in length, and consists of around 200,000 words. Not only was the final report available on the Internet but all evidence, both written and spoken, was available on the Internet also. In this respect it can be seen as a global event. The report itself is simply entitled ‘The Victoria Climbié Inquiry’ and the cover also states that its Chairman was Lord Laming. It was made clear that the report is the responsibility of Lord Laming and 7 the inquiry panel was set up with four assessors to help him with the task. It is a much bigger and more expensive operation. The counsel for the Maria Colwell inquiry consisted of two QCs and the inquiry team was supported by one secretary. Seven parties to the inquiry had legal representation. In contrast, the inquiry staff for the Victoria Climbié consisted of: one secretary to the inquiry; one solicitor to the inquiry; three counsel to the inquiry; a secretariat consisting of seven people; a legal team consisting of thirteen people; two special advisors; two people listed as communications; and seven people as being provided by two separate groups of contractors; plus one person as sound. The legal representatives for the interested parties before the Victoria Climbié consisted of: four London boroughs; three health trusts; one health authority; the Metropolitan Police; the NSPCC; eight police officers; and one social worker. Added to this, there were twenty witnesses with legal representation. In the Maria Colwell inquiry: sixty- five witnesses were examined; there were five witnesses who gave expert evidence; and thirteen witnesses who provided statements which were read in whole or in part by the committee. In contrast, in the Victoria Climbié inquiry: 159 witnesses presented evidence both orally and in writing; 119 witnesses presented evidence in writing only; and just one witness provided oral evidence only; a total of 278 witnesses. In addition the Victoria Climbié inquiry – in order to address its recommendations for the future – organised five seminars which had 120 participants. The Maria Colwell inquiry had its preliminary hearing on 24 August 1973 and then was sitting between 9 October 1973 and 7 December 1973. In contrast, the Victoria 10 smiling, enthusiastic little girl – brought to this country by a relative for ‘a better life’ – ended her days the victim of almost unimaginable cruelty. The horror of what happened to her during her last months was captured by Counsel to the Inquiry, Neil Garnham QC, who told the Inquiry: ‘The food would be cold and would be given to her on a piece of plastic while she was tied up in the bath. She would eat it like a dog, pushing her face to the plate. Except, of course, a dog is not usually tied up in a plastic bag full of its excrement. To say that Kouao and Manning treated Victoria like a dog would be wholly unfair; she was treated worse than a dog.’ 1.2 On 12 January 2001, Victoria’s great-aunt Marie-Therese Kouao and Karl John Manning were convicted of her murder.’ This much more personalised writing style in the Climbié inquiry report is particularly powerful in the way it contrasts the guilty and the innocent, and the way key actors were seen to have failed in key responsibilities. More particularly the inquiry report sees itself, partly a reflection of its much broader brief, as having a key mission on behalf of many children well beyond Victoria. Victoria is portrayed as a symbol of what can happen to children when they are not appropriately protected and cared for. For example, if we look at the second half of paragraph 1.66 quoted above, it reads: . . . throughout, we have all kept a clear focus on the facts and on finding out what happened to Victoria, why things happened in the way they did and how such terrible events may be prevented in the future. I am convinced that the 11 answer lies in doing relatively straightforward things well. Adhering to this principle will have a significant impact on the lives of vulnerable children. The Victoria Climbié inquiry provides a coherent, convincing and powerful account of what happened to Victoria, how she was failed and how this can be avoided in the future. While the account in the Maria Colwell inquiry is of a similar nature, it is also much more equivocal. This is in part because the inquiry report has within it the minority report written by one of the inquiry team, Olive Stevenson. It is not that the report has a major dispute over the facts, but it is in their interpretation, particularly in relation to some of the early decisions leading up to why Maria was returned home, from her foster carers, that there is something of a difference of opinion. In her minority report, included as chapter five in the Maria Colwell report, Olive Stevenson writes as follows: As a social worker, my education and experience has taught me that in such matters, there is no one truth; in considering the subtleties of human emotions everyone is subjective. One’s feelings, attitudes and experience colour one’s perception. This is as true for me as it is for my colleagues. And when one is dealing with events now some time in the past, drawing to a large extent on records for evidence, and inevitably affected by the eventual tragedy, the probability of distortion in interpretation is all the greater’ (para. 2.47). And later: 12 Those who have worked in child care social work have learnt of the impossibility of predicting the future (para. 2.62). Clearly, the Maria Colwell inquiry and its subsequent report had the impact of catapulting the issue of child abuse as a professional multi-disciplinary responsibility onto public and political agendas. The way this was picked up, particularly by the high profile exposure in the media, inevitably lost some of the subtleties and nuances embedded within the report. In many respects, this is similarly the case with the Victoria Climbié inquiry. At the same time, I think it is interesting that the way the respective stories are constructed within the reports is in many respects very different. As the quotations above from Olive Stevenson demonstrate, there was no suggestion in the Maria Colwell inquiry report that the answers to the problems were necessarily simple or straightforward. While the systems set up following the Maria Colwell inquiry publication provided the key policy, practice and procedural frameworks for the ensuing thirty years, there was never an assumption that solutions were necessarily straightforward or the issues anything less than complex. These are points I will return to as part of my conclusion. Before looking at more substantive differences between the two cases, I think it is also important to reflect on an important contextual issue within which both were reporting and operating. The Maria Colwell inquiry was the first of the modern child abuse inquiries, and in many respects had the impact of establishing child abuse as a social problem about which we as a society, and certain organisations and professionals in particular, had a responsibility to do something about. As a result the issue of child abuse in the subsequent thirty years has received considerable 15 Globalisation and Identity Perhaps the major difference between the two cases is literally in relation to issues about the identity of the two children. There was never any doubt in relation to the Maria Colwell inquiry that everybody, including the inquiry team and the professionals involved, knew who Maria Colwell was. There was never any doubt that her mother was her mother, her stepfather was her stepfather, and that Maria had both brothers and sisters and half-brothers and half-sisters. While complicated, and often highly charged, nor was there any doubt about the nature of her extended family and that her immediate family were well known on the estate where they lived, often for quite infamous reasons. The neighbours were heavily involved in reporting concerns to the local social services department and the NSPCC, and similar concerns were evident in the schools which she attended. A major issue was related to the failure of the appropriate agencies to respond appropriately to these referrals and to piece the information together. In many respects it was the furore within the local community in Brighton which provided a major impetus for establishing the public inquiry in the first place. Not only was Maria white and English speaking but that was also the case with everyone, including the worker, involved with her. The estate on which she lived was almost exclusively white and fairly traditional working class, and this was one of the issues which exercised the inquiry. For in many respects the Colwell/Kepple household had all of the characteristics associated with ‘a problem family’ which marked it out as troublesome and disreputable in an essentially solid, respectable working-class and lower middle-class environment. However, it is clear Maria had a 16 name, a known mother, an address and a school. In this respect she could be seen to have a clear identity and location. Hardly any of these characteristics were evident in relation to Victoria Climbié. While the two children were of similar age and suffered similar injuries, in many respects these are the only things they have in common. It was only after Victoria’s death that her ‘real’ identity became known. Similarly, it was only after her death that it became apparent that Marie-Therese Kouao was not her real mother but was ‘a great aunt’ and that her parents lived in the Ivory Coast. There are major issues about her national identity, the nature of her entry into the UK, whether she ever had a permanent address, the fact that she did not have a school or a GP, and that on numerous occasions the various health and welfare departments did not realise they were actually dealing with the same child and ‘family’. Who had ‘parental responsibility’ was particularly confusing and was never clearly addressed or resolved within the inquiry report. In many ways all of these important issues reflect many of the significant social and cultural changes that have been going on in this country during the intervening thirty years. In the Maria Colwell inquiry a major issues was concerned with trying to judge how significant the issue of the ‘blood tie’ was in relation to the decision making, and how this was appropriately addressed. Such issues now seem remarkably old fashioned. There is now considerable variation and complexity in household and family structure and relationships, such that the model of the traditional nuclear family no longer seems to represent the majority of the population. As a consequence we now usually refer the ‘family’ as opposed to the family. Such changes pose major 17 challenges for professionals and agencies whose prime responsibility is to children and families in the context of these huge variations (Featherstone, 2003). The other major area for social change over the intervening thirty years is probably concerned with globalisation. Issues related to and arising from this are core to the Victoria Climbié in a way which is hardly evident with Maria Colwell. While both reports discuss the importance of cultural differences between the workers and the adults and children with whom they work, the way this is discussed is very different. For example, in Olive Stevenson’s minority report she discusses (see in particular para. 285) the cultural differences that were possible in the way Mr Keppel, Maria’s stepfather, made sense of and responded to Maria’s behaviour compared to the way the professionals might have analysed this. It is not in the least uncommon for men and women from such backgrounds to view with astonishment the notion of problems of emotional adjustment. And Mr Keppel was quite right in reminding Miss Lees (the social worker) that in some cultures children are ‘borrowed and returned’ between relatives, with no fuss or bother! . . . Furthermore, even in our own society, it is not uncommon for men to leave such matters ‘to the wife’ and for both men and women to have difficulty in imagining in advance what difficulties may arise’ (para. 2.85). The cultural differences are seen essentially in terms of social class and gender. I find it notable that Diana Lees, Maria’s social worker, when she left social work, took up a post with the Foreign Office. While not necessarily typical we are pointing here to 20 It is obvious to us, as was Dr White Franklin’s (an expert witness to the inquiry) opinion that the child had very strong feelings and was demonstrating them in a significant way . . . what we do consider wholly wrong is that no effort, even at that late stage, was made to obtain a medical opinion as to the depth and significance of Maria’s continuing protests (para. 66). A major problem identified in the Maria Colwell inquiry was the failure to persuade Maria’s mother to get her medically examined at certain key times when there seemed to be evidence of injuries. She was not medically examined, her injuries were not treated, and crucially the nature and possible implications of these injuries were not included as part of the overall picture. Such physical signs were seen as a key indicator of what had previously been called the ‘battered child syndrome’ but which was little recognised by professionals (see Kemp et al, 1962). A major element of the subsequent DHSS circulars was to bring this phenomenon to professional attention and try to encourage professionals, particularly social workers, to recognise a syndrome which had previously gone unrecognised. Medical diagnosis was seen not simply as a part of the clinical picture but a key mechanism for raising professional and public awareness. Medical diagnosis was seen as something to be encouraged and developed and was not seen as problematic in other ways. The situation in the Victoria Climbié case is, however, very different, where two hospitals played a significant role. A major issue in the inquiry is to establish the nature of the clinical symptoms that were being presented, and in particular whether and how far these could be seen as ‘scabies’. There are numerous points in the report 21 where disagreements and disputes between hospital doctors are discussed (see, for example, paragraphs 6.347 to paragraph 6.379); there is one section of the report in particular, however, which is very illuminating. Dr Dempster duly faxed a letter across to the duty team on 15 July 1999, the content of which Dr Schwartz was subsequently to describe as ‘very superficial’. The key passage that was to have such an impact on how Victoria’s case was handled not only by Brent Social Services but also by Haringey Social Services thereafter reads as follows: ‘She (Victoria) was admitted to the ward last night with concerns re possible NAI (non-accidental injury). She had, however, been assessed by the consultant, Dr Schwartz, and it has been decided that her scratch marks are all due to scabies thus it is no longer a child protection issue (para. 5.147). Not only does the report demonstrate numerous examples where ‘erroneous’ medical diagnosis and communications had a tragic impact on the way the case was handled by other professionals, but it also clearly argues that medical diagnosis and opinion must not be treated at face value and uncritically. Both social workers, police officers and other doctors were found culpable in this respect. The contribution of medical expertise cannot, therefore, be seen as providing either easy answers or be treated unproblematically. This is clearly quite a challenge. Whereas the introduction of child protection procedures over the previous thirty years could be seen to have had the explicit intention of trying to circumscribe professional discretion, particularly on the part of social workers, it is now seen as important that they should exercise this discretion and in particular have the ability and authority to challenge other 22 professionals, in particular paediatricians, as appropriate and act with a degree of independence. Problems with doctors and nurses, however, are not only seen as residing with the nature of their clinical assessments and diagnoses. A major issue identified in the Victoria Climbié inquiry concerns the way information is managed within hospitals and between hospitals and other health and welfare organisations. There are a number of examples where it is felt there was no system operating which was designed to ensure that requests for information and work to be done were followed up and that there was a lack of what the inquiry terms ‘systematic care’. It argues: The accurate and efficient recording of information cannot be left to the individual diligence of the doctors and nurses concerned. They must be supported by a clear system that minimises the risks of mistakes and provides a mechanism for recognising mistakes when they occur. The greater the pressures are on staff, the greater the need for a system to support them. The busier the organisation, the more important it is to have a system that ensures agreed actions are recorded and completed (para. 11.36). It was felt that the management of Victoria’s care at the two hospitals concerned was thoroughly inadequate. 25 numbers, creating ample scope for information loss and case mismanagement (para. 5.116). What we see here is an important and significant shift. Whereas in the case of Maria Colwell the problems were derived primarily from failure to communicate between case workers, in relation to Victoria Climbié the problems were much more in relation to wide-ranging and complex system failures, of which communication between individual workers is simply a part. This is a consequence not only of the growth of a variety of new procedures which has taken place over the intervening thirty years, but also the growth in use of information technology of one sort or another for a variety of purposes. The failures were not so much in sharing information but managing information, and it is in this respect that the notion of ‘systematic care’ is seen as so important for ensuring that information and knowledge are managed rigorously, and where there are clear lines of accountability and responsibility. All of these have seen important developments over the intervening thirty years. The growth of information technology, the increasing hyper- circulation of knowledge and communication, and the need to try to manage this, have all become important organisational issues. It is in this context that there has been a growth of concern not just about coordination but about how these things are managed. Managerialisation For many, including the media, one of the unique contributions of the Victoria Climbié inquiry has been the identification of senior managers as well as frontline 26 practitioners as being responsible for the tragic outcome. The report itself is very different in this respect to the Maria Colwell report. There are large sections which talk about the organisational and managerial contexts of the work. This is particularly in relation to the four social service departments involved, as well as the child protection teams in the police. Interestingly, rather less is said in relation to the organisational and managerial contexts of the health service personnel. Again, we are presented with something of a conundrum. There is no doubt that the last thirty years have witnessed a tremendous sea change in the way health and welfare services are organised with an increasing emphasis on the need for clear and strong leadership, and more specifically the growth of managerialisation (Clark, Gerwirtz and McLaughlin, 2000; Newman, 2001). The increased emphasis on managerialism has been seen as a key way in which the failures of the old welfare systems could be overcome during the 1970s, 1980s and 1990s. The previous emphasis on the role of professionals and administrative bureaucrats was seen as inadequate for the new situation that welfare found itself in. In this respect local authority child welfare work could be seen as a key exemplar of ‘old’ welfare. What the Climbié report seems to indicate, however, is that rather than resolving the problems these changes have simply changed the nature of the problems. The report argues that senior managers and others spent far too much time not taking responsibility and not appreciating the nature of the work that was going on in ‘the front office’. A major focus of the report is to try and ensure that in the future issues concerning responsibility and accountability are addressed. However, there is another area where the changes over the last thirty years are also evident in the Climbié report. Unlike the Maria Colwell inquiry, at various points 27 there is extensive discussion about the role, import and appropriateness of a number of joint reviews and external inspections and audits that were carried out in relation to both local authority social services and the police. Again, the last thirty years have seen an enormous growth in ‘audit’ (Power, 1998) of which public inquiries play a key part. However, rather than clarifying and resolving issues it seems that these changes have again simply changed the nature of the problems to be addressed. The growth of managerialisation, audit, procedural guidance and new systems of information technology and information management, all seem to have contributed to an increasing complexity in the nature of the work as far as frontline professionals are concerned. While introduced with all the best of intentions, it is not self-evident in the Victoria Climbié report that their impacts have been positive. In trying to manage and order uncertainty it seems that new uncertainties and complexities have been unearthed. Trust and Uncertainty The introduction of new procedures and systems have been designed not simply to aid internal communication between system members, but to try and ensure a more transparent and accountable system to the wider public. As already intimated, this at best has only been partially successful. However, another, probably unintended, consequence has been the undermining in trust of the professionals themselves which also has an impact upon their morale and mutual confidence. Diana Lees, the local authority social worker at the centre of the Maria Colwell inquiry, was subjected to considerable opprobrium by both the local community and the national media. She was perhaps the first social worker to receive such high profile and critical publicity. 30 welfare practice in this country has come to, is open to debate. Simply comparing these two reports, however, suggests there have been huge and fundamental changes over this thirty period which cannot be underestimated in terms of their impact on professionals or the people they are working with. In part, it may reflect the changing responsibilities and remit of those agencies over the period. Legislative Contexts and Focus of Responsibility At the beginning of the DHSS study of child abuse inquiry reports published in 1982 (DHSS, 19820) there is a quotation which reads: . . . a story unfolds in the report of small carelessnesses, pressures of other work, difficulties of staffing and human procrastinations and failure to cooperate, by which few workers, if they are honest, have not at times been tempted from their standards, but which collectively resulted in individual tragedy and public scandal (this quotation is taken from Jean Heywood, writing in 1958 about the Monckton Inquiry, which was set up in 1945 after the death of Dennis O’Neill whilst in care. (Jean Heywood: Children in Care; Routledge and Kegan Paul, 1959) (DHSS, 1982, p.iii). In many respects this quotation could have been taken from either the Maria Colwell or the Victoria Climbié inquiry reports. At a superficial reading the issues are remarkably similar. I would suggest, however, there are some very important differences. Dennis O’Neill was literally in the care of the local authority and had been ‘boarded out’ with foster carers in South Wales; Maria Colwell had been in the 31 care of the local authority, again with foster carers who were relatives, but had subsequently had the care order removed and was now on a supervision order, again to a local authority; Victoria Climbié was none of these. There was a very brief period when she was on a police protection order but otherwise issues in the report are centrally concerned with trying to discuss whether the case was handled appropriately as a child in need or a child protection case. Put at its crudest, the legislative context in 1945 was such that Victoria Climbié would not have been seen as the responsibility of the local authority. Similarly, it is unlikely that she would have been seen as the responsibility of the local authority in 1973 either. However, following the 1989 Children Act the responsibilities of local authorities changed significantly, particularly a Section 17 of that Act which gives statutory responsibilities in relation to children in need. As the Victoria Climbié inquiry illustrates, the resources available to the local authorities are not available to fulfil these wide-ranging responsibilities, although clearly they are responsibilities which they have to be seen to be fulfilling. This places them in a very difficult situation. Up until now these have been addressed in terms of debates, for example, concerning the relationship between family support and child protection (see, for example, Parton, 1997). What the Victoria Climbié inquiry demonstrates quite explicitly is that the prioritisation of work in this way is no longer adequate. If a child is responded to inadequately as a child in need, particularly if this is done in an unfocused and unsystematic way, the implications for all concerned are no different than if it was a Section 47 investigation. If we look, therefore, over the last sixty years, and even over the last thirty years, it becomes apparent that the responsibilities of local authority social service departments, and in many respects the other agencies with 32 which they work, have broadened considerably. It is in this context that we now talk of safeguarding children, together with their well-being and vulnerability: . . . the single most important change in the future must be the drawing of a clear line of accountability from the top to the bottom without doubt or ambiguity about who is responsible at every level for the well-being of vulnerable children . . . (my emphasis, para. 1.2). The implication of this to me is that while at any one time there will only be a small minority of children in a local authority who will be on the formal case loads of a social worker, and an even smaller proportion who will be on either a child protection register or in the care of the local authority, its responsibilities are very wide. The wording of ‘Children in Need’ as the key rationale for these developments is such that the department has responsibilities for all children, all of the time, in its geographical area, and, as we have seen, the nature of this child population, in certain areas, is itself extremely mobile and diverse. Conclusion I am thoroughly in support of Lord Laming’s argument that the answer to our current problems is in ‘doing the relatively straightforward things well’. At the same time, I do not think we should underestimate the considerable complexity that has come to characterise the child protection systems and child welfare work more generally over the last thirty years. In comparing in a very crude way the Maria Colwell inquiry and the Victoria Climbié inquiry, I have demonstrated that issues around globalisation,