For the answer to this profoundly important question journalists have been referred by Gloucestershire County Council to the report it commissioned from the Bridge Childcare Consultancy. Yet this report, published as the jury delivered its final verdict last Wednesday, raises more questions than it answers.
A careful reading first of all elicits the extraordinary information that Gloucestershire County Council and Constabulary have effectively investigated themselves. Although the inquiry was managed by independent consultants, four members of the team were full-time members of the social services department, and two were from the police.
Furthermore, the investigation did not include formal interviews with any of the staff who dealt with the Wests over a 27-year period, or examination of the files they kept. Instead, at a cost of pounds 1m, the team relied on reviews prepared by the agencies themselves - the county council and the police.
In the words of Norman Warner, the respected child-care consultant who chaired the Government's 1992 inquiry into children's homes: "The process used to compile the report hardly establishes public confidence." He has called for a more independent review.
The Gloucester Area Child Protection Committee (ACPC) has also published its own document, entitled "Key Questions Answered - Contacts between the Public Services and the West family 1965-1994". These "key questions", however, do not include many that the media have been asking for months.
Both reports omit crucial information on schools attended by the West children. The ACPC states: "All the head teachers of schools attended recall that the children seemed cared for and their attendance gave no cause for concern, and in some cases was singled out for praise."
Yet, as we revealed in Dispatches, Anne Marie West's own school report showed that in 1979 she was absent from Linden School for 68 days in the school year. Not only was her absenteeism remarked upon in her reports, so were her mood swings. She later confessed to having been a bully. There is, moreover, no mention in the Bridge report of the bruising detected in 1973 by a teacher at St Paul's School in Gloucester, when she was nine, or of the visit paid thereafter by a welfare officer.
The Bridge report also does not mention the signs of disturbance exhibited at school by her younger half-sister, Heather, murdered by the Wests in 1987. She ran away on a camping trip to the Forest of Dean in her second year, developed an ill-disguised hatred for men, and was suspended. Frederick and Rosemary West were called to the school to discuss her behaviour.
Furthermore, two of Heather's school friends recounted an occasion on which a teacher noticed bruising on her. Heather claimed it was from play-fighting with her brothers.
Marie Gardner, to whom Heather confessed the extent of her parents' abuse, told us: "One of the PE teachers took her into the little office that's in the changing rooms and ... questioned her about the bruising because it was quite obvious. You couldn't miss it really." Sheadded: "The bruising were [sic] in funny places. It was the inside of her legs and, like, the top of her arm, you know it was like hand-grip bruises." "Key Questions" states: "There is no record or recollection by teachers of bruising ever having been seen on Heather West."
More disturbing is the claim by another daughter, Mae West, that in 1987 she was unable to interest a teacher in the fact that Heather, who had just left the school, had disappeared without trace. The Bridge report also nowhere reflects the fact that Mae was reluctant to undress for PE, never participated in any outside instruction activity, or that Rosemary and Frederick West never attended any school parent evening.
The official account is vague about the number of contacts between the West family and social services. The county council says that until 1992 no one told social services of any suspicions. Yet a council welfare officer had visited Cromwell Street about Anne Marie's bruising in 1973, and in 1985 there was a meeting with the family after a warning that Rosemary West was a prostitute. The council admits that in 1988 "an anonymous caller reported that the children were being left alone", but the caller, Arthur Dodds, says he actually warned about child abuse.
Perhaps most open to question is the claim by the Bridge report that "it was not until the publication of national guidelines in 1988 that guidance was available on the identification of child sexual abuse". Although sexual abuse itself was not specifically mentioned in legislation until the late 1980s, formal arrangements were in place to protect children from all types of physical abuse from the early 1970s.
After the first major public outcry over the death of a child through abuse - Maria Colwell, in 1974 - Gloucestershire area review committee was set up. Itsmembers were supposed to use its machinery to share information between public bodies but failed to do so - a fact acknowledged by the Bridge report. By the late 1980s, each public body in Gloucester had lengthy records on the Wests, from school and hospital files to Frederick West's criminal records, which showed 10 court appearances and a prison sentence. There was, in addition, the rape of 17-year-old Caroline Owens in 1972, for which the Wests, charged with indecent assault, were fined pounds 50 each.
Furthermore, between 1972 and 1992, there were 31 instances of the West children being treated at hospital accident and emergency departments. None resulted in a referral to social services.
The Bridge report remarks that "it is possible to see there were worrying signs hidden in the mass of medical notes". Yet it does not highlight the fact that the West children were not identified as victims of abuse until 1992. Nor is there any mention of Gloucester Royal Hospital's failure to follow procedures on placing children on a special abuse register.
From the early 1970s, guidelines stated that a child would be eligible for being put on the register if "the nature of an injury is not consistent with an account of how it occurred, or where there is ... a reasonable suspicion that injury was inflicted by any person having custody or care of a child". Not only were West family members treated for thrush and a minor for gonorrhoea, but there was a catalogue of injuries to tendons, fingers and chests, as well as lacerations between the toes of the children, some supposedly self-inflicted. Scratches on Anne Marie in 1973 were noticed by a paediatrician but no action was taken.
The Bridge report does not mention a vaginal injury to seven-year-old Anne Marie in 1971, which followed an assault by Frederick and Rosemary West. This was treated at Gloucester Royal Hospital and the Wests claimed it was an accident caused by a "chopper" bike.
Nor does the Bridge report mention her under-age ectopic pregnancy, caused by Frederick West in 1980. Anne Marie was never interviewed alone. Even though she had suffered criminal sexual abuse, neither social workers nor police were informed. The ACPC's sole observation is that "an interview with her father gave the impression of being a caring and attentive parent concerned for his daughter's well-being".
In a post-trial statement, the chief executive of Gloucestershire County Council, Michael Honey, said: "These murders would never have come to light but for the detailed co-operation and partnership between Gloucestershire County Council staff and police." He attributed the collapse of a first set of child-abuse proceedings against the Wests in 1992 to the fact that "the victims were terrorised into silence". But the eldest West daughter, Anne Marie, has accused the authorities of failing to give her sufficient support during those proceedings: "I felt I was in need of some sort of protection, not so much for myself but for my children. This was not forthcoming. I lived relatively close to my father and stepmother at the time, and I was aware that she was out on bail ... I didn't think anyone realised what I meant about being afraid." She withdrew her statement and the Wests were not re-arrested for eight months.
If there is one significant finding in the Bridge report it is in its investigation of links between a former care home in Gloucester and the Wests. Two of their victims were from Jordans Brook House, and a van similar to Fred West's was reported to have visited the home on a number of occasions. The Wests were known to have preyed on vulnerable girls: six of their victims spent time in care.
In 1977 a runaway from Jordans Brook was raped at 25 Cromwell Street, but survived. Two years later Alison Chambers, another absconder, was murdered. The report contains the previously unknown fact that 22 young people who disappeared from Jordans Brook between 1970 and 1994 are still missing. Its recommendations, which are limited to questions of improving record-keeping in children's homes, appear a missed opportunity, in the light of such an extraordinary finding.
In this country, 250,000 people disappear every year, many from care homes, and efforts to find them are mainly left to charities. The Bridge report might have contributed to calls for a comprehensive national tracing system.
No sooner had Rosemary West made her journey from courthouse to prison last Wednesday than the heads of the public bodies lined up to explain why detection of her crimes took so long. The police officer in charge of the case, Detective Superintendent John Bennett, began by attacking the media for intruding in the case and troubling relatives.
Twenty years ago the police would have been well advised to focus on the Worcester Evening News, which had linked, as the police failed to do, the disappearances of four of West's victims, three of whom had disappeared from bus stops. Mary Bastholm, for whom Mr Bennett had searched as a police diver in 1968, was linked not only with Lucy Partington, but also Shirley Hubbard and Carol Cooper. It took Gloucestershire police nearly quarter of a century to do the same. If the main conclusion of the Bridge report is that "none of the information could be said to indicate the presence of potential multiple murders", then the question it fails to answer is why?
Tanya Sillem and Paul Wandless reported and produced ITN's 'Dispatches' for Channel 4: "The Shame of Cromwell Street", broadcast last Wednesday.