Victoria was an 8 year old girl that died in February 2000. Kouao and Manning, her aunt and partner, were found guilty of murder and sentenced to life imprisonment in January 2001. An Inquiry was set up in April 2001, chaired by Lord Laming with a report Published on 28 January 2003. This report made 108 recommendations. The Children Act 2004 was the legislative spine for the reform and the Every Child Matters: Change for Children was the implementation programme set by the Government.

This infamous picture below shows all the missed opportunities by a plethora of agencies and professionals. If we drew similar ones in many of the serious cases reviews lessons learnt I have no doubt we would find them to be similar.

I often think back to this horrific case and the media circus and ‘blame culture’ that followed. Now, twenty years on as we reflect, has anything changed? Is our child protection system a child friendly one?  Continuing child deaths preceded and a further review by Professor Eileen Munro Review was conducted in 2011 to understand if the system is accessible for children and families. Listed at the end are just some of the children that have continued to suffer significant harm which resulted in their death.   We have to look at these serious cases through structuralism of legislation and policy. In this context the UK Governments over the last decade have proceeded to issue guidance and publications on information sharing, thresholds, measurable outcomes for children and their families, multi-agency responsibilities, concepts of partnerships, etcetera.  Does this help or hinder practitioners to keep the welfare of the child at the forefront of practise?

How far have things changed since then? Nothing like as much as I would have hoped, to me the system is still not child friendly, it doesn’t equally capture the child’s voice and is often unsatisfactory at intervening early to rescue, support or protect our children from significant harm.  It is little wonder that children ‘fall through the net’, agencies having missed opportunities, nor share relevant information and in fact worked in silos and not within a multi-agency context.

Lord Laming claimed at the time that Victoria’s death would mark a ‘turning point in ensuring proper protection of children in this country’ (Hopkins, 2007). However, most publicly, the case of Peter Connelly (Haringey, 2008), a seventeen-month-old baby boy who was killed in 2007 in the same London Borough as Victoria Climbié, along with the continuing rising number of child deaths caused by maltreatment (Brandon et al., 2012), supports an argument of enduring systemic failings within the social care and health sectors (Munro, 2011). The inquiry and other research echoed that there continued to be ‘practice’ and ‘systematic risks’ within the system (Webb, 2006; Pithouse et al., 2001).  (Extracted from, Carlick, 20018, p.12)

Following Victoria and Peter’s deaths and the Review of the Child Protection System by Professor Eileen Munro (2011) it concluded with 15 recommendations. The report beckoned for a more child-focused system rather than one centred on meeting central government targets. So I urge for reflection in 2020 on where is the child’s journey and where is the child’s voice? Somehow the child still appears to be ‘lost’ in a system designed to protect them…sadly I do not believe that a great deal has changed and we must look to included children as equal parts. Furthermore technical innovations and early help and multi-agency working must take on new conceptual frameworks and new forms of action and enquiry if we are to not repeat the same poor practices. I advocate for new debates and conversations not to do what we have always done and therefore we aim to reduce the number of child deaths in this country.

List of some Child Deaths:

  • 2000   Victoria Climbie, aged 8 – Starved and beaten to death by her great aunt and her boyfriend
  • 2002   Ainlee Walker, aged 2 – Died from 64 separate injuries inflicted by parents
  • 2003   Natalie Mills, aged 15 – Died after being assaulted by her boyfriend
  • 2007   Peter Connelly, aged 18 months, Died after receiving catalogue of abuse from mother and her boyfriend
  • 2008   Brandon Muir, aged 23months – Died from ruptured intestine inflicted by mother’s boyfriend
  • 2010   Rebecca (5yrs) and Daniel Smith(11mths)  –  Died when mother suffocated them with plastic bags in Lloret De Mar. Father had been extradited to England on child sex abuse charges. Family reported missing in England in 2006.
  • 2012   Daniel Pelka aged 4 –  starved and beaten to death by mother Magdelena and her partner Marius- sentenced to 30 years imprisonment each August 2013
  • 2014  Ayeeshia Smith  aged 21 months murdered by her mother Kathryn Smith. Partner  Matthew Rigby convicted of allowing the death of a child- suffered serious likened to car crash victims.
  • 2017 Dylan Tiffin-Brown aged 2 years beaten to death by drug dealer father

Recently published case reviews:

  • 2018 Emily Death of a 3-month-old girl in March 2015 as the result of Sudden Unexpected Death in Infancy (SUDI).
  • 2018 Young Person. Death by suicide of a 17-year-old young person in 2016. There were over 30 multi-agency contacts or events involving the young person and/or their close family in the ten-month period prior to the young person’s death.
  • 2018 Death of a 3-month-old Black British/Caribbean girl September 2016 from cardiac arrest. After her death, Child C was found to have multiple fractures consistent with non-accidental injuries.
  • 2018 – Bexley – John. Fractured skull to a 13-month-old boy in March 2017. Parents sought medical advice because of a swelling to John’s head but were not able to explain how the injury had occurred; they advised the paediatrician that he was a very active child with a habit of head banging.
  • 2019 Death by suicide of a teenage girl in January 2019.
  • 2019Death of a 14-year-old young person from an aggressive malignant tumour.
    Child F’s voice was heard but was not understood and acted on; evidence of poor inter-agency communication and information sharing; the need to manage conflict and work with challenging carers whilst not losing focus on the child; quality of care issues raised by Child F received an inadequate response by Children’s Social Care.

(Accessed 11.02.2020

Dr Sarah Carlick