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Thursday, 11 July, 2002, 14:02 GMT 15:02 UK
Could Victoria have been saved?
Why did Victoria Climbie die? Was this a murder that nobody could have prevented? Or did the child protection system fail?
At the public inquiry, counsel to the hearings Neil Garnham QC outlined a dozen occasions when authorities had a chance to intervene.
One: Ealing social services, spring 1999
Victoria Climbie first became known to social services when she arrived with her aunt, Marie-Therese Kouao, in the London borough of Ealing.
Between 26 April and 7 July, Marie-Therese visited social workers 14 times in her pursuit of housing support so that she could stay in England. Victoria was with her on seven visits.
Staff who saw Victoria had two concerns. Firstly, some noticed that the relationship between Kouao and Victoria was not one of mother and daughter. Secondly, one member of staff, Deborah Gaunt, described Victoria's dishevelled appearance as akin to a child on an "Action Aid poster".
Ealing wanted Kouao to return to France, arguing that she had no rights to benefits.
Staff who saw the pair may have concluded that Victoria's appearance was part of an attempt to persuade the authorities to hand out money.
Two: Warnings from a relative
Ealing eventually found Kouao and Victoria somewhere to live in neighbouring Brent.
In June 1999, Ester Ackah, a distant relative by marriage of Kouao, anonymously telephoned social workers in Brent and warned them that Victoria was in danger.
1What happened to the information is unclear. Senior social worker Edward Armstrong denies that his team received details of a potentially serious child protection case. He said his team were told of a case where a child was not in school.
Two social workers tried unsuccessfully to see Kouao on 14 July, almost a month after the warning. No further action was taken by the authority.
Social work experts say that a parent or guardian's failure to ensure a child gets proper schooling is sometimes an early warning of other child abuse.
Three: First hospital admission
The first time that doctors saw Victoria Climbie was when she was admitted to the Central Middlesex Hospital on 14 July 1999. Some weeks before, Marie-Therese had moved in with Carl Manning with whom she had started having an affair.
Victoria was taken to hospital when Avril Cameron, the daughter of her childminder, believed the girl had been scratched and cut. Dr Ekundayo Ajaye-Obe told the inquiry that he did not accept the explanation from Kouao that Victoria had caused the injuries by scratching scabies sores.
He referred Victoria to the hospital's consultant paediatrician, Dr Ruby Schwartz. She over-ruled Dr Ajaye-Obe's diagnosis and agreed that the wounds were the result of scratching at scabies sores. Kouao took Victoria home.
At the inquiry, Dr Schwartz said that while she did not suspect physical abuse, she did have other concerns.
Confusingly, a letter to social services, written by yet another doctor, said that there were no child protection issues.
Neil Garnham QC, counsel to the inquiry, described the failure of others to question the apparent differences of opinion at the hospital as "disturbing".
"It was as if the critical faculties of all other professionals were simply suspended," he told the inquiry.
Four: Visits to Ealing social services
Kouao visited Ealing social services the day after Victoria had been discharged from hospital.
Staff at the office said that the case, which they considered to be a housing issue, was closed.
Neil Garnham QC told the inquiry that this visit represented a missed opportunity to intervene because staff at Ealing should have been aware of the case history to date.
Five: Second hospital admission
On 24 July Victoria was admitted to North Middlesex Hospital suffering scalding to her head and face.
Social services did not ask Victoria what had happened until she had been in hospital for two weeks, by which point she was being discharged to the care of Kouao. There were no arrangements for her to be monitored. With Kouao and Victoria now living with Carl Manning, the case was in Haringey council's hands.
The designated social worker, Lisa Arthurworrey, has apparently not handled such a complicated case previously in her career.
What exacerbated the situation, the inquiry heard, was that there was little exchange of information between the hospital and social services.
Counsel to the inquiry Neil Garnham QC said this led a "battle of conflicting assumptions" where each body believed that the other was fully aware of the suspicons.
Doctors believed that Victoria had been abused - but did not realise that neither social services nor the police were aware of the evidence.
PC Karen Jones, the police officer assigned to the case, did not visit Kouao or Manning prior to Victoria's discharge because she feared that she may have caught scabies.
Six: Tottenham child and family centre
Barry Almeida, a senior Haringey social worker, referred Victoria Climbie's case to the NSPCC-run Tottenham Child and Family Centre on 5 August 1999.
However, the centre was confused as to why it was being handed the file - the notes suggested that it would not be their kind of case.
The centre's Sylvia Henry says she spoke to Mr Almeida to clarify matters and was told that the family were no longer in the borough so the case had actually been closed. At the inquiry, Mr Almeida said that he had no recollection of this conversation.
Seven: Health visitor follow-up
This issue proved to be one of the most contested points in the inquiry with two completely conflicting versions of events.
Rachel Crowe of North Middlesex Hospital said that she referred the Victoria Climbie case to a community health visitor, Luana Brown. Ms Brown says that she did not receive any instructions or papers to follow-up the case.
Eight: Visit to Carl Manning's flat
Social worker Lisa Arthurworrey eventually made two visits Carl Manning's flat after Victoria had been discharged, the first being on 16 August 1999.
Counsel for the inquiry Neil Garnham QC argued that Ms Arthurworrey did not see through an act put on by Manning and Kouao.
"It may be thought that the fact that they succeeded so conspicuously [in fooling the social worker] is attributable in part to Miss Arthurworrey's willingness to accept what she saw and heard at face value," he told the inquiry.
"She never troubled to speak to Victoria during those two visits. She never sought to discover how Victoria spent her days ... she never sought to take any active steps to address the fact that Victoria was not receiving any education."
Nine: Letter to Petra Kitchman
On 13 August, Mary Rossiter, consultant paediatrician at North Middlesex Hospital, wrote to Petra Kitchman, Haringey's child protection link with the hospital.
Ms Kitchman said the letter did not arrive for another seven days. What happened next remains unclear. Ms Kitchman said that she relayed these concerns to Lisa Arthurworrey. Ms Arthurworrey says that she did not.
10: Second letter to Petra Kitchman
Dr Rossiter's second letter to Ms Kitchman on 2 September 1999, containing details of the evidence of abuse recorded at the hospital, arrived while the social worker was on leave.
Ms Kitchman said that on her return she raised this with Ms Arthurworrey, something that the case worker denies. In her evidence, Ms Arthurworrey said that had she sent the letter or the medical details she would have "run to her manager".
11: Sexual abuse allegations
Kouao telephoned Haringey social services on 1 November 1999 and alleged that Carl Manning had sexually abused Victoria.
At the inquiry, Neil Garnham QC said that the allegation was probably untrue but gave both the police and social services and opportunity to investigate. Had they done so at this stage, they would have discovered that the girl was suffering serious and continual abuse at the hands of Manning and Kouao.
Kouao withdrew the allegations the next day but social workers decided to press on with a special meeting to discuss Victoria. The team agreed that 15 steps needed to be taken - steps that largely focused on making contact with Kouao, Manning and Victoria.
12: Final visits to Manning's flat
Lisa Arthurworrey told the inquiry she attempted to contact Kouao in person with three visits to Carl Manning's flat between December 1999 and January 2000. On all three occasions she received no answer.
Ms Arthurworrey told her supervisors that it was possible that the pair had finally returned to France.
Despite no evidence to support this theory, case notes from 23 December, written by Ms Arthurworrey's supervisor, concluded that Kouao and Victoria had "left the area".
On 18 February, the social workers again wrote to Kouao saying that the case, still regarded as a housing matter, would be closed if she did not contact the department.
Haringey social services closed Victoria Climbie's case on 25 February 2000.
At 3.30pm the same afternoon, Victoria, who had sustained months of abuse, was declared dead in St Mary's Hospital, Paddington.
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