Victoria Adjo Climbié (2 November 1991 – 25 February 2000) was an eight-year-old Ivorian girl who was tortured and murdered by her great-aunt, Marie-Thérèse Kouao, and Kouao's boyfriend, Carl Manning. Her death led to a public inquiry and produced major changes in child protection policies in the United Kingdom.
Born in Abobo, Côte d'Ivoire, Victoria Climbié left the country with her great-aunt for an education in France, before they moved to London, England, in April 1999. It is not known exactly when Kouao started abusing Victoria, although it is suspected to have begun when they met and moved in with Manning. The couple would burn her with cigarettes, scald her with hot water, starve her, and hit her with bicycle chains, hammers, wooden spoons, and their bare hands. After Victoria died, Kouao and Manning were both convicted of murder and sentenced to life imprisonment.
The police, the social services department of four local authorities, the National Health Service, the National Society for the Prevention of Cruelty to Children (NSPCC), and local churches all had contact with Victoria and noted signs of abuse, but little action was taken. After her death, a report by Lord Laming made numerous recommendations related to child protection in England. Victoria's death played a large for the formation of the Every Child Matters initiative; the introduction of the Children Act 2004; and the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner for England.
Life
Victoria Adjo Climbié was born on 2 November 1991 in Abobo, Ivory Coast, the fifth of seven children. Her parents were Francis Climbié and his wife Berthe Amoissi. Marie-Thérèse Kouao, Francis' aunt, was born on 17 July 1956 in Bonoua, Ivory Coast, and lived in France with her three sons, claiming welfare benefits. She divorced her former husband in 1978, and he died in 1995. Kouao was attending her brother's funeral in the Ivory Coast when she visited the Climbié family in October 1998. She informed them that she wanted to take a child back to France with her and arrange for their education; this sort of informal fosterage is common in the family's society. Victoria was apparently happy to be chosen, and although her parents had met Kouao only a few times, they were satisfied with the arrangements.
From that point onwards, Kouao fraudulently maintained that Victoria was her daughter. Kouao had originally planned to take another young girl called Anna Kouao, but Anna's parents changed their minds. Victoria travelled on a French passport in the name of Anna Kouao, and was known as "Anna" throughout her life in the United Kingdom. It is not known exactly when Kouao started abusing Victoria. Victoria's parents received three messages about her from when she left them until her death, all saying she was in good health.
Paris
Marie-Therese Kouao and Victoria Climbié left the Ivory Coast possibly in November 1998 and flew to Paris, France, where Victoria enrolled at school. By December 1998, however, Kouao began to receive warnings about Victoria's absences, and in February 1999, the school issued a child-at-risk notification and a social worker became involved. The school observed how Victoria tended to fall asleep in class, and the headteacher later recalled Kouao's mentioning Victoria suffering from some form of dermatological condition and that, on her last visit to the school on 25 March 1999, Victoria had a shaven head and was wearing a wig. When they left France, Kouao owed the authorities £2,000, after being wrongly paid in child benefit, and it is claimed that Kouao viewed Victoria as a useful tool for claiming benefits. Kouao had also been evicted from her home in France because of rent arrears.
London
On 24 April 1999, Kouao and Victoria left France and relocated to England, where they settled in Ealing, West London. They had a reservation in a bed and breakfast at Twyford Crescent, Acton, where they lived until 1 May 1999, when they moved to Nicoll Road, Harlesden, in the London Borough of Brent. On 25 April 1999, Kouao and Victoria visited Esther Ackah, a distant relative of Kouao by marriage, and a midwife, counsellor, and preacher. Ackah and her daughter noted that Victoria was wearing a wig and looked small and frail. On 26 April 1999, Kouao and Victoria visited the Homeless Persons' Unit of Ealing Council, where they were seen by Julie Winter, a homeless persons' officer. Together, Kouao and Winter completed a housing application form. Kouao explained that Victoria was wearing a wig because she had short hair, an explanation accepted by Winter. Although Winter was shown Victoria's passport (with a photograph of Anna), she paid no attention to them, believing that Kouao's application was ineligible on the grounds of habitual residence. Winter confirmed her decision with her duty senior and told Kouao that she was not eligible for housing. She telephoned the referral across to Pamela Fortune, a social worker in Ealing's Acton referral and assessment team. She did not produce a written or electronic documentation of the referral, however, something which would have helped in double-checking the accounts that Kouao gave.
Between 26 April and early July 1999, Kouao visited Ealing social services 18 times for housing and financial purposes. Victoria was with her on at least ten occasions. The staff there noted Victoria's unkempt appearance, with one staff member, Deborah Gaunt, thinking that she looked like a child from an ActionAid advertisement. However, they did not take any action, and may have assumed that Victoria's appearance was a purposeful attempt to "persuade the authorities to hand out money". On 8 June 1999, Kouao got a job at Northwick Park Hospital. During her first month, no effort was made by Kouao or Ealing social services to enroll Victoria in educational or daycare activities.
On 8 June 1999, Kouao took Victoria to a local GP surgery. The practice nurse there did not carry out a physical examination, as Victoria was not reported to have any current health problems. By the middle of June 1999, Victoria was spending the majority of her days at the Brent home of Priscilla Cameron, an unregistered childminder, whom Kouao met at her job in the hospital. There is no evidence that Victoria was treated badly during her time with Cameron. On several occasions, Cameron observed small cuts on Victoria's fingers. When questioned by Cameron, Kouao said that they were caused by razor blades that Victoria had played with. Kouao and Victoria met Ackah on the street on or around 14 June 1999. In what may have been early signs of deliberate physical harm, Ackah noted a scar on Victoria's cheek, which Kouao said was caused by a fall on an escalator. On 17 June 1999, in response to what she had seen three days earlier, Ackah visited Kouao and Victoria's home, and thought that the accommodation was unsuitable.
On 18 June 1999, Ackah anonymously telephoned Brent social services, expressing concern over Victoria's situation. Samantha Hunt, the customer-service officer who received the call at the One Stop Shop at Brent House, faxed the referral to the children's social work department on that same day. Nobody picked up the referral on that Friday afternoon, and what happened to it was—according to Lord Laming, who headed the subsequent inquiry—the subject of "some of the most bizarre and contradictory evidence" the inquiry heard. A few days later, possibly on 21 June 1999, Ackah phoned Brent social services again to make sure her concerns were being addressed. Ackah said that she was told by the person on the other end of the telephone that "probably they [social services] had done something about it". This call, however, did not trigger a new, separate referral.
The first referral was not seen until three weeks later on 6 July 1999, when Robert Smith, the group administrative officer, logged the details of the referral onto the computer, with details of Victoria's injuries. Laming said the delay constituted "a significant missed opportunity" to protect Victoria. Edward Armstrong, the team manager of the intake duty team, said that he completed a duty manager's action sheet not for the 18 June referral, which he said never arrived in his office, but for the 21 June referral, which was a less serious case than the first; Laming called this version of events "wholly unbelievable". Laming said that Armstrong's evidence was out of line with that of the other Brent witnesses, that the quality of it "[left] much to be desired", and that Armstrong's insistence that he dealt with the 21 June referral was an attempt to cover up his team's "inept handling" of a genuine child protection case.
On 14 June 1999, Kouao and Victoria met Carl Manning (born 31 October 1972) on a bus which he was driving. This was the start of Kouao and Manning's relationship, which ended at the time of their arrest eight months later. She was his first girlfriend. The relationship developed quickly, and on 6 July 1999, Kouao and Victoria moved into Manning's one-bedroom flat at Somerset Gardens in Tottenham, in the London Borough of Haringey. There is evidence that Victoria's abuse increased soon after moving into Manning's flat.
On 7 July 1999, Brent social services sent a letter to Nicoll Road, where Kouao and Victoria were staying, informing them of a home visit. On 14 July 1999, two social workers, Lori Hobbs and Monica Bridgeman, visited the address but found no answer: Kouao and Victoria had already moved out on 6 July 1999. Hobbs and Bridgeman made no further inquiries at the property, inquiries that might have led to a trail on Victoria's whereabouts. Prior to the visit, they had not done any background checks, and had only the "haziest idea" of what they were investigating. The Laming report suggests that no reports or follow-up notes were made and that the only information additional to the referral were the notes "Not at this address. Have moved."
First hospital admission
On 13 July 1999, Kouao took Victoria to the childminder, Cameron, asking her to take Victoria permanently, because Manning did not want her. Cameron refused to accept Kouao's request, but agreed to take her for the night. Cameron, her son Patrick, and her daughter Avril, observed that Victoria had numerous injuries—including a burn on her face and a loose piece of skin hanging from her right eyelid—which Kouao said was self-inflicted. Manning's account in the subsequent inquiry differed, and he said that he hit Victoria because of her incontinence, beginning with slaps, but progressing to using his fist by the end of July. It was highly likely that at least some of the injuries were the result of deliberate physical harm.
The next day, on 14 July 1999, Cameron's daughter Avril took Victoria to see Marie Cader, a French teacher at her son's school. Cader advised that Victoria be taken to a hospital. At 11:00 am the same day, Avril took Victoria to the Accident and Emergency department of Central Middlesex Hospital. At 11:50 am, Victoria was seen by Dr Rhys Beynon, a senior house officer in the department. Beynon took Victoria's history from Avril, and thought that there was a strong possibility that the injuries were non-accidental. He referred the case to Dr Ekundayo Ajayi-Obe, the on-call paediatric registrar. Beynon conducted only a cursory examination of Victoria, as he believed she was going to be examined by the paediatric team. The Laming report said that "he exhibited sound judgement in his care of Victoria by referring her immediately to a paediatric registrar." Victoria arrived at Barnaby Bear ward where she was examined by Ajayi-Obe, who noted various injuries. When asked about the injuries, Victoria said they were self-inflicted, a claim the paediatrician did not think was credible. Having examined Victoria, the paediatrician was "strongly suspicious" that the injuries were non-accidental, and she decided to admit Victoria onto the ward.
The doctors alerted Brent police and social services, and she was placed under police protection, with a 72-hour protection order preventing her from leaving hospital. Kouao told the doctors that she had scabies, and that the injuries were self-inflicted. Many doctors and nurses suspected that the injuries were non-accidental. However, Ruby Schwartz, the consultant paediatrician and named child protection doctor at the hospital, diagnosed scabies and decided that it was scratching that caused the injuries. She made the diagnosis without speaking to Victoria alone. Schwartz later admitted that she made a mistake. Another doctor, one of Schwartz's juniors, misleadingly wrote to social services, saying that there was "no child protection issue".