The prolonged torture and murder of an eight-year-old girl who was kept trussed in a bin liner during her final days led to the publication yesterday of an inquiry report that condemned every professional organisation involved in her care.
Lord Laming's inquiry into the killing of Victoria Climbié, who died in February 2000, said the failure of the agencies involved to protect her was a disgrace. His report advocates massive reform of Britain's childcare system, with a new framework of safeguards to prevent such a scandal from happening again.
Among his 108 recommendations are the appointment of a children's commissioner for England, reporting to a board to be chaired by a cabinet minister, and the establishment of a national database to track every child's health, welfare and educational progress.
Despite the involvement of four social service departments, two housing departments and two specialised child protection teams of the Metropolitan Police, Victoria died having been starved, beaten and neglected for months, with 128 injuries on her body.
"Not one of the agencies empowered by Parliament to protect children in positions similar to Victoria's – funded from the public purse – emerge from this inquiry with much credit," the report says.
Alan Milburn, the Secretary of State for Health, announced fundamental changes to children's services in response to the 400-page report. He said a series of "children's trusts" would be set up to bring all local services for children under one organisation to "remove the barriers" between services.
Training is also to be reviewed, new national standards introduced and clearer guidance issued to try to stop such "unspeakable abuse" being allowed to happen again.
Victoria was sent by her parents from the Ivory Coast to live with her great-aunt in Britain in search of a better life. Instead she found "unimaginable cruelty", sustaining daily beatings from her aunt, Marie-Thérèse Kouao, and her boyfriend, Carl Manning. Both are serving life sentences for her murder.
Victoria's parents, Francis and Berthe, who attended the inquiry, said after the publication of the report yesterday they were upset that no one had accepted responsibility for their daughter's death. Mr Climbié added: "We are happy some of the officers involved in this case have been sacked but we are not satisfied, because just by sacking the lower rank of the agencies involved in this case, the problems are not going to disappear. How about the people at the top?"
Lord Laming said there was a "catalogue of administrative, managerial and professional failure by the services charged with her safety". Although a number of frontline staff have since left, he accused senior managers of being responsible for the "greatest failure".
Ian Willmore, former deputy leader of Haringey council, said managers and local politicians should be "considering their positions". Haringey council accepted responsibility yesterday and the National Society for the Prevention of Cruelty to Children apologised for its failings.
The suffering and death of Victoria was "a gross failure of the system and inexcusable", Lord Laming said. The failing was not with the law but the professionals whose "sloppy, unprofessional performance" led to more than a dozen opportunities to intervene and save Victoria being missed.
In Ealing, staff were given guidance that was so out of date it did not include the Children Act of 1989. In neither the Central Middlesex Hospital nor the North Middlesex Hospital was a full evaluation of Victoria's needs completed.
"On each occasion Victoria was admitted to hospital, vitally important information went unrecorded and staff failed to act on their suspicions and observations," he said.
Although she was referred to an NSPCC centre, it made no attempt to contact her. The last time a social worker from Haringey went to Victoria's house, she left thinking the girl had moved to France. "Victoria was, in all probability, a few yards from her, tied up in the bath," he said. His recommendations were not calling for change in due course but "an agenda for action now". Half should be implemented in three months. "The best we can hope for from the terrible ordeal suffered by Victoria, who was brought to this country for a better life, is that this report is the last of its kind," he said.