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Cite as: [2004] EWCST 268(PC)

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Arthurworrey v Secretary of State for Education and Skills [2004] EWCST 268(PC) (9 June 2005)

Lisa Arthurworrey

-v-

Secretary of State for Education and Skills

[2004] 268.PC

-Before-

His Honour Judge David Pearl

(President)

Mr Brian Cairns

Ms Maxine Harris

Heard at the Care Standards Tribunal on 23^rd, 24^th, 25^th, 26^th and 27^th May 2005.

For the Appellant: Mr Peter Jackson QC and Mr Mark Jarman of Counsel instructed by Venters Solicitors

For the Respondent: Mr Philip Coppel of Counsel

DECISION

A. Background

Lord Laming commenced his Report of an Inquiry into the death of Victoria Climbie (Cm 5730, January 2003) with the following words: "This Report begins and ends with Victoria Climbie. It is right that it should do so. The purpose of this Inquiry has been to find out why this once happy, smiling, enthusiastic little girl – brought to this country by a relative for 'a better life' – ended her days the victim of almost imaginable cruelty".

This hearing has a much narrower remit. We are constituted as a Tribunal to hear the appeal brought by Ms Lisa Arthurworrey, Victoria Climbie's social worker, against the decision of the Secretary of State to place her on the list of those who are deemed unsuitable to work with children (the PoCa list).

We of course have had the benefit of reading Lord Laming's Report. So far as findings of fact and the drawing of conclusions based on those facts are concerned, we follow the approach set out in the judgment of Leveson J in Secretary of State for Education and Skills v Mairs [2005] EWHC 996(Admin). He said: "Without any discourtesy…the conclusions on the facts are Lord Laming's opinion based on his assessment of the evidence and cannot possibly bind the Tribunal which is required by statute to reach its own conclusions on the matters in issue. Common sense dictates that the views expressed following a statutory Inquiry undertaken with a wide ranging remit will be highly persuasive and will require careful consideration….[the Tribunal must exercise] its own judgment in accordance with its obligations under the 1999 Act albeit paying appropriate attention to the views of the Inquiry and doubtless explaining for reasons of clarity where and why it takes a different view"

In the event, there is no issue of disputed fact requiring a decision by this Tribunal. The conclusions based on the facts are our conclusions and we do not consider ourselves bound by Lord Laming's report although we have given his conclusions very careful thought.

Victoria died on 25^th February 2000. On 12^th January 2001, Victoria's great-aunt, Marie-Therese Kouao, and her partner, Carl John Manning, were convicted of her murder.

As we have said, this appeal is concerned with one consequence of this tragedy. Ms Lisa Arthurworrey, a social worker employed by the London Borough of Haringey, and who had been allocated Victoria's case by her then supervisor, Ms Carole Baptiste on 30^th July 1999, was suspended from duty on 31^st October 2000. This followed a Review Panel Part 8 Enquiry that had reported on 25^th October 2000.

Subsequently, Mr Bernard Monaghan, a senior manager of the Family Welfare Association, was engaged by Haringey Housing and Social Services Department to conduct an investigation under the Council's Disciplinary Code of Conduct in order to establish (i) whether there was evidence of a breach of the disciplinary code by one or more officers; (ii) the seriousness of such a breach, and (iii) where relevant, the grounds for disciplinary action. He reported on 15^th May 2001.

There was a Disciplinary Hearing by Haringey on 16^th and 17^th September 2002. Ms Arthurworrey did not attend the hearing because of illness. She was advised on the following day that she had been dismissed. Haringey wrote a letter to the Respondent on 23^rd September 2002 drawing the Respondent's attention to Ms Arthurworrey's dismissal and the reasons why this action had been taken. She was provisionally placed on the list established by s1 of the Protection of Children Act 1999 (the PoCa list) on 27^th September 2002.

The Respondent confirmed the provisional listing on 6^th November 2003, and a notice of appeal to this Tribunal was filed on 5^th February 2004.

We heard the appeal over a period of five days, and received oral evidence from Mr Bernard Monaghan on behalf of the Respondent; and Ms Arthurworrey, her father Mr John Arthurworrey, Detective Sergeant Michael Cooper-Bland now of the Metropolitan Police, Child Abuse Investigation Command and Ms Liz Davies, a Senior Lecturer in Social Work at the London Metropolitan University on behalf of the Appellant.

We heard submissions on the weight that we should attach to Mr Monaghan's Report. We rejected the submission made by Mr Coppel that "if this Tribunal is to displace what Mr Monaghan said in his Report, it must be accompanied by good and sufficient reasons." This Tribunal has a statutory duty to provide reasons for all its conclusions. But we do not give Mr Monaghan's Report the same status as Lord Laming's Inquiry. Mr Monaghan produced a Report for Haringey for the specific purpose of enabling Haringey to consider whether there should be disciplinary proceedings. Evidence was not taken under oath. In so far as he drew certain conclusions about Ms Arthurworrey's conduct, we have looked at his conclusions, and indeed have set them against any contrary conclusions made by Ms Davies in her evidence to us on behalf of the Appellant. Mr Monaghan was never asked to consider the test laid down in s 4 of the Protection of Children Act 1999. That is this Tribunal's responsibility. Thus, we do not provide any special status to the evidence and conclusions of Mr Monaghan.

It is common ground between Mr Coppel and Mr Jackson that there is no significant dispute between the parties on either the factual basis in this appeal, nor indeed the law that has to be applied. The issue that we have to determine is how to correctly assess the facts.

B. The Law.

The appeal is brought under section 4(3) of the Protection of Children Act 1999. This states:

"If on an appeal or determination under this section the Tribunal is not satisfied of either of the following, namely –

(a) that the individual was guilty of misconduct (whether or not in the course of his duties) which harmed a child or placed a child at risk of harm; and

(b) that the individual is unsuitable to work with children,

the Tribunal shall allow the appeal or determine the issue in the individual's favour and (in either case) direct his removal from the list; otherwise it shall dismiss the appeal or direct the individual's inclusion in the list.

The burden of proof rests on the Secretary of State to satisfy us to the civil standard both that the Appellant was guilty of misconduct that harmed a child or placed a child at risk of harm, and that she is unsuitable to work with children. It is not alleged in this case that Ms Arthurworrey harmed Victoria, rather that she "placed her at risk of harm".

It is also agreed that the Act is wide enough to include misconduct by omission. (See Angella Mairs v Secretary of State [2004] 269.PC upheld [2005] EWHC 996(Admin), Leveson J), and Mrs MD v Secretary of State [2004] 234.PC: failure by a mother to report that a family member had sexually abused her daughter).

In his opening submission, Mr Jackson stated that "the term 'misconduct' should be construed in accordance with the purpose of the legislation, which is to reduce the risk of harm to children without stigmatising individuals who do not pose a threat". Mr Jackson submitted also that for incompetence to be misconduct it must be serious and gross and not merely consist of mistakes arising from inexperience, immaturity or lack of appropriate supervision. In his closing submission, Mr Jackson departed somewhat from this formulation, accepting that incompetence at a certain level can be capable of being misconduct. He said that it was a matter of judgement as to when the threshold is reached.

We are entitled to look at the Parliamentary debates in giving meaning to the use of the word "misconduct." We were referred to the exchange in Parliament on 10^th March 1999 between Ms Debra Shipley MP (the sponsor of the Private Members' Bill) and Ms Jacquie Ballard MP, when Ms Shipley MP said "I have been persuaded that serious and gross incompetence would be covered by misconduct…" She did not say that anything short of "serious and gross" would not be so covered, and we are not persuaded that any attempt to place a gloss on the word "misconduct" is particularly helpful in this context.

We have read carefully the decision of our colleagues in Angella Mairs v Secretary of State [2004] 269.PC and in particular paragraph 109 where that Tribunal discusses the meaning of "misconduct" at some length. The Tribunal said:

"In the context of a profession, for there to be a finding of misconduct there must be a falling short, whether by omission or commission, of the standards of conduct expected from members of that profession (Doughty v General Dental Council [1987] 3 All ER 843).

It is not helpful to attempt to further refine "misconduct" by reference to any adjective having moral overtones. The word "misconduct" does not necessarily connote moral censure. An individual can be "guilty of misconduct" without being, for example, dishonest or disgraceful.

An individual is not guilty of misconduct if he or she was unable to avoid the improper act or omission complained of or was in a position where it was impossible to avoid breaching the relevant code of conduct. If the requirement to act properly or in accordance with a code was merely rendered more difficult by the acts or omissions of others or by the prevailing circumstances, there can still be a finding of misconduct. Mitigation of an offence is always possible and, where the circumstances are such that the individual guilty of misconduct was overworked, short of time and/or unsupported it may be possible to excuse his or her misconduct. However, misconduct is only extinguished when the extenuating circumstances rendered proper performance of a duty impossible as opposed to more difficult."

Mr Jackson took issue with the final sentence of that formulation, suggesting it to be an unhelpful and impermissible gloss on the concept of misconduct.

It is our view that a case of alleged professional misconduct must be looked at in context. There will be examples of simple mistakes made by a senior professional that will inevitably attract the characteristic of "misconduct", whilst other much more serious mistakes but made by a relatively junior professional will fall the other side of the line. Many factors will play a part in this analysis, some of the factors involving the individual; others, the task that was required; and in some cases, it will be necessary to consider the responsibilities of others.

There is a considerable level of agreement between Mr Coppel and Mr Jackson on the correct test that must be applied.

Mr Coppel, in his closing submissions states as follows: "The Respondent readily accepts that what is a 'mistake' may fall short of 'misconduct' by reason of one of six factors. The six factors are identified by the Respondent as (i) the complexity of the case; (ii) the adequacy of the training; (iii) lack of sufficient experience; (iv) lack of proper supervision; (v) a dysfunctional working environment; and (vi) an excessive workload.

In his opening Statement, Mr Jackson states that Ms Arthurworrey acknowledges the extent of her shortcomings, but asks that they be assessed "with an understanding of the reality of her position." Mr Jackson highlights 11 factors that need to be assessed when considering whether her actions or omissions constitute 'misconduct.' The eleven factors are as follows:

• Inexperience

• Lack of essential training

• Non-existent leadership

• Useless supervision

• Inadequate local procedures

• Chaotic and demoralised work environment

• Excessive caseload and overwork

• Allocation to a case beyond her capacity

• Misleading information from senior medical staff

• National organisational and resource shortcomings

• Plausible murderous adults

Mr Coppel submits that each of his six factors needs to be examined against the evidence and once that is done, the Tribunal should turn to the particular omissions one-by-one asking itself whether the six factors in aggregate and in the circumstances should excuse the Appellant sufficiently so that the omission cannot be characterised as 'misconduct.' Although he did not address Mr Jackson's eleven factors as set out above, many of them can be encompassed into Mr Coppel's list.

The danger in Mr Coppel's submission, however, is that it risks a reversal of the burden of proof. This remains firmly on the Secretary of State throughout and it is his burden to satisfy us to the appropriate standard that none of the mitigating factors apply.

We were referred to the Department of Health "Practical Guide to the Act for all Organisations Working with Children", and in particular to paragraph 7.7. This is concerned with the circumstances where a referral to the Secretary of State is required under s 2 (and also s 2A) of the Protection of Children Act 1999. It does not deal with appeals under s 4(3). Nonetheless, the statement in this Guide that "misconduct would range from serious sexual abuse through to physical abuse which may include intentional inappropriate restraint and/or poor child care practices in contravention of organisational codes of conduct which resulted in harm or risk of harm to children" is too broad a brush to be of help. In any event, in 1999/2000, the General Social Care Council had yet to be established and a national formal Code of Practice for professional social workers did not exist.

The approach we have adopted in this case is to look carefully at the entire period, from 14^th July 1999 when Victoria was admitted to the Central Middlesex Hospital to her tragic death on the 25^th February 2000. We have examined Ms Arthurworrey's role as the allocated social worker from 2^nd August 1999 when she received the file, paying particular regard to the allegations of misconduct and her replies to these allegations as set out in the documents that we have seen.

C. A Summary of the Agreed Facts

The details of Victoria's story are non-contentious and we set out as much as is required in this judgement so as to provide the necessary background to our assessment.

Victoria arrived in UK with Ms Marie-Therese Kouao (who posed as Victoria's mother) on 24^th April 1999. She appeared in Ms Kouao's passport in the name of Anna.

14^th – 15^th July 1999. She was admitted into the Central Middlesex Hospital at 10.55am on 14^th July 1999. She was taken there by her childminder's daughter (Ms Avril Cameron).

A doctor saw her within an hour of her arrival and the results of the basic examination so concerned the doctor that she was referred to a paediatric registrar, Dr Ajayi-Obe. This doctor performed a more extensive physical examination and discovered a large number of marks to Victoria's body that she recorded on a set of body maps. She formed the view that at least some of the marks might be non-accidental injuries. She arranged for Victoria to be admitted overnight. The police were informed, and she was placed under police protection at 5.20pm on the 14^th July.

Ms Kouao arrived at the hospital that evening, and she was there when Dr R Schwartz saw Victoria as part of her evening ward round. As a result of her examination that evening, Dr Schwartz concluded that Victoria was suffering from scabies.

The following morning, after the police had withdrawn their protection, Ms Kouao returned to the hospital and left with Victoria.

24^th July 1999. On 24^th July 1999 at 5.30pm. Ms Kouao brought Victoria into the North Middlesex Hospital. She had a serious scald to the face, and Ms Kouao said that this was caused by Victoria placing her head under the hot tap in the bathroom to try to relieve the itching caused by scabies.

She was admitted to the paediatric ward (the Rainbow ward) where she stayed for the next 13 nights. Lord Laming states that at about 11.00pm on the date of admission, Dr S Forlee, the house officer who first examined her, explained the position to Haringey Social Services. A more detailed referral was made three days later by Karen Johns, an Enfield social worker based at the hospital. The duty officer at the time was Caroline Rodgers. The duty manager, Shanti Jacob, ordered a strategy meeting.

28^th July 1999. The strategy meeting took place on 28^th July 1999, attended by Ms Rose Kozinos, the practice manager who chaired the meeting, Ms Caroline Rodgers, Ms Karen Johns, and WPC Karen Jones (a police constable from the Haringey Police Child Protection Team). Eighteen recommendations were made. The plan for protecting the child was stated to be "full investigation and assessment." It was agreed that a Child Protection Conference was not required at this stage.

30^th July – 2^nd August 1999. On 30^th July 1999, Ms Arthurworrey became involved for the first time, when her supervisor, Ms Carole Baptiste, allocated the case to her. She received the file, which consists of fifteen pages, on 2^nd August 1999.

Ms Arthurworrey says in her witness statement that when she received the file she went to see Ms Baptiste who told her that "it was about a child who was in hospital with scabies" and that she should read and implement the Strategy Recommendations.

2^nd August 1999. Her file note dated 2^nd August 1999 states

• Obtain medical report from Dr Folley (sic) examining paediatrician of concerns re previous NAI and current concerns

• Obtain report from hospital S/W [Social Worker]re concerns of neglect

• Once medical reports are received joint H/V [Home Visit] with the police to be arranged

• Interview to address recent incident. Old injuries and neglect issues

• Interpreter will be required for the family as they speak French

• Basic checks to be completed. Hospital SW to inform when child is ready for discharge

• Contact between mother and child to be monitored by hospital staff whilst child is in hospital

• Hospital SW to inquire into how photographs of Anna's injuries can be passed to the PCPT [Police Child Protection Team].

• Checks in France where other family members reside to be completed

• PCPT will complete immigration checks

3^rd August 1999. Ms Arthurworrey received a fax from Ms Johns, the Hospital Social Worker, on 3^rd August 1999. This fax reads as follows: "I have been informed that Anna is now ready for discharge and the ward would like this to happen as soon as possible…I should also mentioned that Anna's scabies has been successfully treated and is therefore no longer active."

Ms Arthurworrey made two telephone calls on the 3^rd August 1999, namely to Isabel Quinn a Senior Staff Nurse at the North Middlesex Hospital and Dr Mary Rossiter, the hospital's named doctor for child protection.

We have seen the file note of her phone call to Ms Quinn. The note says: "Hospital are satisfied with the explanation given by Anna's mother re her burns. Explanation was that Anna who had been suffering from scabies had poured hot water from a kettle over her head. She did this to relieve the itching. However, when Dr Forly (sic) examined her noticed old injuries, which appeared to be non-accidental. Therefore the hospital concerns are around these old injuries." The file note refers also to other concerns, namely Victoria's state of dress, her behaviour towards her mother, the mother's response to Victoria's accident, discrepancies over the timing of the incident, and that Victoria had wet herself in the mother's company.

Ms Quinn sent Ms Arthurworrey an 11 page fax at 12.23pm on the 3^rd August 1999. This fax refers to observations in the hospital; the fact that Victoria was brought into hospital in an unkempt manner compared with Ms Kouao's attire; the "master and servant attitude" between Victoria and Ms Kouao, that Victoria had wet herself when Ms Kouao was present, that Ms Kouao had brought in no clothes or toiletries or treats for Victoria when visiting; that Victoria ate very large amounts of food (one morning she had five bowls of cereal). The fax included body maps.

The file note of the telephone call on the 3^rd August 1999 with Dr Rossiter states: "Dr Rossiter feels Anna may be subject to emotional abuse. Believes she is displaying evidence of anxious attachments." The file note of this telephone conversation refers to the "master and servant" relationship between Victoria and Ms Kouao. It would seem that Dr Rossiter told Ms Arthurworrey about the scabies, and she said that the mother had over-treated this condition, and "that is when child poured hot water over her skin." Dr Rossiter said that it was unclear that the marks on Victoria's body were a result of Victoria scratching herself or infection from the scratching.

Arrangements were made for a Home Visit on 4^th August 1999 with an interpreter, to carry out a risk assessment, but WPC Karen Jones called on the 4^th to inform Ms Arthurworrey that the hospital had had discussions with her about health and safety issues arising out of the fact that scabies is a highly infectious disease. In the result, the home visit was cancelled and Ms Kouao was offered an office visit.

5^th August 1999. Ms Arthurworrey and WPC Jones interviewed Ms Kouao with the aid of a French interpreter in the offices of Haringey Social Services on 5^th August 1999. Interestingly, the file note of this interview explains that Victoria had poured a beaker of hot water from the bath tap over her head whilst taking a bath "to try and reduce her skin irritation" and consequently she burned herself. There is no mention of a kettle. In her evidence to us, Ms Arthurworrey told us that they did not obtain much information from the interview, although the main impression she received was that Ms Kouao was avoiding child protection issues. She identified her level of concern at that time between somewhere in the middle of a range 1-5.

6^th August 1999. Ms Arthurworrey and WPC Jones visited Victoria in hospital on the 6^th August 1999. No interpreter was present. Ms Arthurworrey said that this was due to her speaking to both the hospital and to Ms Kouao who assured her that Victoria had a reasonable command of English. She told us in evidence that she felt at the time that the presence of a third adult would be oppressive for Victoria. The file note occupies just one and a half pages of manuscript. It states: "Karen and I agreed injuries were probably accidental, agreed discharge in the mother's care was appropriate."

Ms Arthurworrey returned to the office and summarised the situation to Ms Baptiste. In her witness statement, Ms Arthurworrey states that Ms Baptiste agreed that it was appropriate for Victoria to be discharged and that she should do a follow up home visit to assess the outstanding concerns.

Victoria was discharged at 8.00pm on 6^th August 1999. As Lord Laming writes at 3.48 "They went straight back to Manning's flat in Somerset Gardens where Victoria was to spend the remaining seven months of her life."

12^th August 1999. There is a gap in the chronology from 6^th August 1999 until 12^th August 1999, when Ms Arthurworrey found some papers in her pigeonhole. This contained a 20-page fax dated 15^th July 1999 from the Central Middlesex Hospital addressed to the Duty Social Worker (Ms C Rodgers). The top page, from Dr Dempster, says: "Thank you for dealing with the social issues…She was admitted to the ward last night with concerns re possible NAI [Non Accidental Injury]. She has however been assessed by the consultant, Dr R Schwartz and it has been decided that her scratch marks are all due to scabies. Thus it is no longer a child protection issue. There are however several social issues that need to be sorted out urgently. Anna and her mother are homeless. Anna does not attend school". The other pages, very difficult to read, contain the medical records and body maps, the police protection documents, and a letter to the Housing Department in Wembley from the Central Middlesex Hospital.

In her witness statement, Ms Arthurworrey states that "Having read the covering letter, I glanced at the medical notes quickly and did not register anything of particular concern". In her evidence to us, she said, "I did not have time to read the full Fax. I could have made time. I skim-read the fax because of the speed my brain was being forced to work at during this time." She accepted before us that this was poor social work practice "in the extreme" and that she should have read the Fax.

Ms Arthurworrey said in her witness statement and in her evidence before us that she took the entire fax to her supervisor, Ms Carole Baptiste, and drew her attention to the letter of 15^th July. She said that Ms Baptiste looked at the letter and flicked through the rest of the fax, and remarked that "the decision to discharge Victoria home had obviously been the correct one and that [Ms Arthurworrey] should sort out the remaining social issues."

Paragraph 117 of her witness statement reflects Ms Arthurworrey's assessment of the situation as of 12^th August 1999, and her view of her approach today:

"It was at this point that the focus of my work changed to family support and away from child protection. My concerns about physical safety had already been considerably diluted by my conversation with Dr Rossiter. I now no longer saw the case as one of potential child abuse but rather of a family struggling to find their feet in a new country. This was obviously a terrible error of judgment but it was my manager's assessment as well as my own. The sequence of events led me to feel a greater level of trust in Kouao. It seemed to me that NMH had rejected a diagnosis of NAI in relation to the scalding, and that in relation to the older marks CMH had specifically considered that they were not due to NAI."

16^th August 1999. Ms Arthurworrey, with an interpreter, made an announced home visit to Manning's flat on 16^th August 1999. Lord Laming (at 3.51-3.52) speaks of Ms Arthurworrey finding Victoria to be smartly dressed and well cared for. Victoria spent most of her visit playing with a doll, and although she did not talk with Victoria during the visit, she formed the impression that Victoria was happy and seemed like "a little ray of sunshine." The meeting lasted for an hour or so, concentrating on the social and housing issues. We have seen the notes of the home visit taken at the time, and no child protection issues are referred to in these notes. Ms Arthurworrey in her evidence to us said that looking back she could see that she should have "dug below the surface" and she accepts that she was "duped" by Manning and Ms Kouao.

The Summary and Action notes however do show that some of the hospitals' concerns around issues of neglect and emotional abuse were discussed during the home visit.

Ms Arthurworrey then wrote a care plan, drafted with an emphasis on family support. The child protection page is crossed through as N/A [Not applicable].

20^th September 1999. There was a Supervision with Ms Carole Baptiste on 20^th September 1999. Ms Arthurworrey's witness statement states "I had supervision with Carole about Victoria's case. It lasted 5-10 minutes. I always brought my files to supervision, but Carole did not look at the file and recorded the case as one of family support and housing. Carole did not refer back to the Strategy Meeting decisions or tell me to take any other steps." Ms Arthurworrey's file note for that day says: "Lisa to chase up outcome of Housing situation. Continue to offer family support until early October." Ms Baptiste's Supervision note occupies 8 lines of manuscript only. It says, "The case identified as family support as CP concerns investigated. Issues of housing. Lisa to give Mum list of child minders…"

1^st October 1999. It would seem that Ms Petra Kitchman, a Haringey Child Protection Adviser visited Ms Arthurworrey about Victoria. Ms Arthurworrey's evidence was that Ms Kitchman told her that she was making enquiries about Victoria on behalf of Dr Rossiter, who had expressed concerns by letter dated 13^th August 1999. The letter was shown to Ms Arthurworrey. It says: "Unfortunately the ward staff seemed to think that Social Workers can discharge patients who are under the care of a Doctor and although I probably would have let the girl go home (she was very eager to do so) at least a consultant should have been informed. I have enormous concerns about this child who is now lost to follow up somewhere in Haringey. What are you going to do?" The file note says "Informed Petra of current situation."

Ms Arthurworrey says in her witness statement that she was not shown a copy of the discharge summary or another letter from Dr Rossiter to Ms Kitchman dated 2^nd September 1999 asking about follow up and enclosing the Discharge Summary dated 13^th August 1999. The discharge summary highlights a number of concerns and refers to the possibility of marks made with looped wires. Ms Kitchman replied to Dr Rossiter on 19^th October 1999, although Ms Arthurworrey states that she did not see this reply until 15^th November 1999. It is not necessary for present purposes to examine this aspect of the chronology in any detail. Lord Laming calls the letter: "On any view it was an extraordinary response." (6.335). We agree. Lord Laming also says "I come to the view that even if Ms Arthurworrey had seen the North Middlesex Hospital Discharge summary in October 1999, it would have had little impact on her handling of the case." (6.356). This issue does not appear as one of the allegations of misconduct, and therefore we express no opinion on whether Ms Arthurworrey was shown the Discharge Summary on 1^st October 1999.

28^th October 1999. There was a second announced home visit on 28^th October 1999. The meeting lasted about 30-45 minutes. There was no interpreter present because Ms Arthurworrey said that it had not been necessary on the previous occasion. Lord Laming states (at 6.366) that this meeting had a single purpose, namely to discuss the options open to the family, given their housing situation. At paragraph 152 of her witness statement, Ms Arthurworrey states "Victoria presented as bright and happy. She was appropriately dressed and sat in the same room, again playing with a doll while we spoke…I did not sense anything wrong. I thought her confident and articulate." The file note states that it was agreed that Ms Arthurworrey would contact the family in a week's time to discuss what had been decided re the long term.

1^st November 1999. Ms Arthurworrey was on duty on this day and about 9.30am she answered a telephone call from Ms Kouao. Apparently she was screaming and shouting in a mixture of French and English about sexual abuse and Manning. Ms Arthurworrey spoke with Ms Rose Kozinos who was her senior on duty that day who told her to ask Ms Kouao and Victoria into the office to discuss the allegation.

An hour later Ms Kouao, Victoria and Manning all appeared in the office. Ms Arthurworrey asked Manning to leave, which he did. She then spoke to Ms Kouao together with a colleague, Ms Robertson. Ms Kouao related three incidents of sexual abuse by Manning on Victoria. These are all related in the file note.

Ms Arthurworrey spoke briefly with Victoria in order to gain her perceptions of life at home. The file note states that "straight away, Anna began to speak about the incidents, in graphic detail almost a repetition of what her mother had informed." Ms Arthurworrey decided to terminate the interview because she felt a police officer should be present. Ms Arthurworrey consulted Ms Rose Kosinos and she was told to arrange the strategy meeting for 5^th November. She reported the matter to the Police Child Protection Team. It was established that the mother had friends in Wood Green and it was agreed that Ms Kouao and Victoria could reside there until the case was investigated fully.

2^nd November 2005. Ms Kouao returned to the Haringey Social Services with Victoria and they were seen by Ms Rose Kosinos. Ms Kouao said that Victoria had been lying the previous day.

5^th November 2005. There was a fifteen-twenty minute strategy meeting with Ms Rose Kosinos as the Chair, Ms Arthurworrey, WPC Jones, and WPC Ricketts. The 15 items of work decided by the Strategy meeting were as follows:

• PCPT to contact immigration re status. S/W to establish which airport client came in on

• S/W to complete a check with France if client previously known. Find out more information re: other children

• Some proof that child is hers

• Check on Carl Manning by PCPT - SW to obtain DofB

• Client to give police a statement/ or one withdrawing

• Full assessment on child re: neglect issues

• Discuss case with legal

• Talk to child on her own with mother's permission

• Need to explore issues of schooling

• Complete check re: medical

• Explore issues of bedwetting / and bereavement of father

• Explore Carl and mother's relationship

• Possible joint home visit with PCPT

• Copies of minutes to PCPT

• Explain Child Protection Procedures to mother and give her copies of leaflets.

15^th November 1999. Ms Arthurworrey had her supervision with Ms Mairs. There has been a dispute between the two of them as to what happened at this meeting. It is not necessary for us to adjudicate on this dispute, because Mr Coppel accepted that Ms Arthurworrey's version of the events is correct. Accordingly, Ms Mairs had Victoria's file in front of her, and Ms Mairs was told about the second strategy meeting. It would seem from the supervision note, that Ms Mairs gave Ms Arthurworrey until 17^th December 1999 to complete the points from this second strategy meeting that were Ms Arthurworrey's responsibility.

19^th November 1999 – 25^th February 2000. Ms Arthurworrey made a number of attempts to contact Ms Kouao. She wrote on the 19^th November asking Ms Kouao to attend for an interview on 1^st December; Ms Kouao did not turn up so Ms Arthurworrey telephoned Ms Kouao's mobile number on 1^st December and received no reply; Ms Arthurworrey telephoned Manning's number on 13^th December, there was no reply and she left a message; she telephoned Ms Kouao's friend's on 13^th December 1999 (with whom Victoria and Ms Kouao were believed to be staying) and she was told that they had returned to live with Manning; she said in evidence that she made two unrecorded spot visits to the flat but was unable to get into the building.

On 23^rd December 1999, Ms Kosinos told Ms Arthurworrey at a supervision meeting to make another spot visit, to complete the appropriate paper work, to update the PCPT and to take "No further action."

Ms Arthurworrey made another visit to Manning's flat on 6^th January 2000 but there was no reply. She rang Manning's number on 6^th January 2000 but again there was no reply. On 10^th January 2000, she contacted Bruce Grove Primary School and was told that Victoria had not been enrolled. She made two telephone calls to WPC Jones to inform her of the situation.

At a further supervision with Ms Kosinos on 20^th February 2000, the case was not discussed, and the file was passed to the team manager, Ms Mairs, for closure.

The file was closed on 25^th February 2000, which was the day Victoria was readmitted to hospital and the day she died.

D. Allegations of misconduct

It is most convenient to set out the allegations as they were presented in Mr Coppel's final submissions. Eleven particulars of misconduct are relied upon. Mr Coppel submits that they are interrelated but demonstration of any number of them is sufficient to constitute misconduct.

First particular of misconduct

A failure on or shortly after 4^th August 1999

(i) to compile a list of information held by Haringey Social Services suggesting that Victoria was at risk of serious harm

(ii) to analyse or evaluate that list or otherwise make such an assessment of the information held by Haringey

(iii) to obtain further information relating to the risk of harm to Victoria

(iv) to check with CMH for further information relating to injuries sustained by Victoria

(v) or otherwise to carry out a proper investigation or assessment of the risk of harm to which Victoria was at that time exposed.

Second particular of misconduct

The failure of the Appellant on 6^th August 1999 to conduct a proper interview with Victoria, being a child who was known to the Appellant to be at risk of harm, in particular

(i) by failing to provide an interpreter

(ii) by continuing to conduct the interview without an interpreter

(iii) by failing to ask questions of Victoria that would have been likely to elicit information as to the circumstances surrounding the previously identified instances of neglect

Third particular of misconduct

This failure relates to the conversation with Dr Rossiter on 3^rd August 1999, and Mr Coppel conceded that it did not feature largely in the Secretary of State's case.

Fourth particular of misconduct

The failure of the Appellant

(i) to read fully

(ii) to consider fully; or

(iii) to discuss with those in the CMH,

the fax sent on 2^nd August 1999 being a fax that contained information, which raised serious doubts as to the safety of Victoria.

Fifth particular of misconduct

The failure of the Appellant on 16^th August 1999 or at any time before to conduct a proper interview with Ms Kouao.

Sixth particular of misconduct

This relates to a failure to convene a strategy meeting as soon as possible after the allegations relating to Manning on 1^st November 1999. Mr Coppel stated in his final submissions that this allegation was "not at the forefront of the Secretary of State's case."

Seventh particular of misconduct

The failure of the Appellant

(i) to convene a CPC in respect of Victoria

(ii) to conduct an enquiry under s 47

(iii) to check the immigration status of Ms Kouao

as soon as reasonably practicable after the 5^th November 1999 strategy meeting.

Eighth particular of misconduct

The failure of the Appellant to undertake the majority of the tasks and/or to

complete all the tasks required of her and identified at the strategy meeting on 5^th November 1999, in particular the failure of the Appellant to instigate any investigative action into the serious concerns of harm to Victoria that resulted from the interviews held on 1^st and 2^nd November with Ms Kouao and Victoria.

Ninth particular of misconduct

The failure of the Appellant to ensure that all of the tasks identified at the strategy

meeting on 5^th November were promptly undertaken; and were completed.

Tenth particular of misconduct

The Appellant having been informed on 15^th December that Victoria had returned to Manning's flat, the failure of the Appellant to ascertain the circumstances of Victoria or to consider seeking statutory orders.

Eleventh particular of misconduct

The failure of the Appellant for over three months after 5^th November to make

contact or to take adequate steps to make contact with Victoria.

E. Do these failures, or some of them, constitute misconduct, which placed Victoria at risk of harm?

Before we look at each of the allegations in turn we consider five general points that are relevant to all of the allegations; namely experience, training, the complexity of the case, the question of supervision, and the office environment.

Experience. The Appellant's Job Application Form to Haringey received on the 5^th June 1998 indicates that the Appellant was born in 1969, that she had a BA degree with class 2.2 honours, and that she had qualified as a social worker in June 1997 with a DipSW/DipHE from the University of Luton secured over a course of two years, including two practice placements neither of which was in a setting mainly concerned with child protection placements.

She worked as a Social Worker in Hammersmith and Fulham for some ten months before joining Haringey, responsible for promoting the overall well being of children and families in that Borough as part of a general Children and Families Team.

Mr Coppel submitted "On any normal view, this equipped her with sufficient

experience to carry out adequately those tasks which she omitted to carry out adequately."

We cannot accept this analysis of Ms Arthurworrey's experience or her qualification as evidence that she was already well fitted to assume responsibility beyond a casework service to families with children in need. Her job description certainly includes a reference to investigation of cases of alleged neglect or ill treatment of clients/service users and "to make enquiries for appropriate recommendations". However we agree with Ms Davies. In her witness statement, she said: "A newly qualified social worker is by definition inexperienced…No social worker with 19 months practice can be described as experienced in child protection work." She referred us to a paper by P.Reder and S.Duncan at vol 13 of the Child Abuse Review pp 95-114 where the authors write, specifically about the interview with Victoria: "The ability to gain the confidence of such a child, to talk with them, to be receptive to what they communicate overtly and covertly and to accommodate to their pace of disclosure requires a high degree of skill and experience gained over many years." We were referred also to the writings of Professor N.Parton exhibited to Ms Davies' written statement.

Training. Ms Davies makes a similar point as regards Ms Arthurworrey's training. She says in her witness statement: "My central point is that Ms Arthurworrey did not have the necessary training to carry out the work expected of her in the Victoria case effectively."

We have had the opportunity of seeing the materials prepared for a course that Ms Arthurworrey attended; a five-day "Working Together" Child Protection awareness course. This is an introductory course, and it does not deal with section 47 procedures in any depth. It constitutes "the menu" rather than "the meal."

We heard evidence from Detective Sergeant Cooper-Bland who was involved in lecturing on that course. He said in his witness statement: "I cannot see how the Haringey 'Working Together' course could equip a social worker to carry out an investigation in accordance with section 47 Children Act 1989, any more than it would enable a police officer to work in child protection. It was not the aim of the course to provide that level of instruction. "Working together" was a multi-agency course designed for a broader audience."

Mr Monaghan, in his evidence before us, acknowledged, after reading the witness statements of Ms Davies and DS Cooper-Bland that his thinking on the adequacy of the training had moved on. He said that he now accepted that the training on the five-day "Working Together" course was of an introductory nature, and did not have a detailed practical quality.

Ms Davies said: "Without training at an advanced level I would not expect Ms Arthurworrey to have understood how to properly investigate an allegation of child abuse. I would not expect her to have understood her role as a social worker in relation to that of the police, the detailed function and purpose of strategy meetings and conferences or how to assess and confront parent/carer responses in relation to child abuse allegations."

Ms Davies said also in her evidence that the type of work that Ms Arthurworrey should have been allocated, given her level of experience and training at that time, should have been child in need assessments, family support work, possibly being involved in child protection work when working jointly with senior and experienced practitioners, and in preparing section 7 reports. We agree with her assessment.

Complexity. We turn now to consider whether the case was complex.

Mr Monaghan in his evidence to us said that it was his opinion that Ms Arthurworrey's experience and training equipped her to carry out basic social work responsibilities. It is our view that Mr Monaghan's opinion may well be accurate in relation to basic responsibilities. We are far from convinced however that the tasks that faced Ms Arthurworrey in dealing with Victoria's case could be described as "basic" or "not complex".

Lord Laming at 6.576 ff writes:

"The proper and well-thought-out allocation of cases is a central component of the effective management of a social work team…It would appear that Victoria's case was allocated to Ms Arthurworrey by Ms Baptiste without any consideration of the sort of factors I have previously described. In the first place, there would seem to have been no assessment of whether Ms Arthurworrey had the requisite capabilities to handle the case. Ms Arthurworrey told me that at the time she found Victoria's case file lying on her desk, she had never completed a section 47 Inquiry, never dealt with a child in hospital and never taken a case through to case conference. For present purposes, what concerns me is not whether Ms Arthurworrey was capable of handling Victoria's case in a competent manner, but that no assessment of her capabilities would seem to have been made by her manager before allocating the case to her...nor would there seem to have been any consideration as to whether [her] work load at the time allowed her to devote enough time to Victoria's case."

Mr Monaghan agreed in his evidence before us that there had been no serious attempt to allocate the case appropriately. However, he insisted that the tasks that needed to be done were not in themselves complex. We simply do not agree.

It is of course true that Haringey were dealing with two highly deviant individuals, and it is easy with the benefit of hindsight to realise that the issue from the beginning was child protection rather than family support. However, even from the perspective of Summer 1999, it is clear that from the paper work that arrived from the North Middlesex Hospital that this was a case with varied child protection concerns that required exploration, that a s 47 enquiry was required, and that interviews were needed with the adults and with the child as a matter of some urgency. There were also issues relating to immigration status, housing and education. It required an appropriate allocation to a social worker with experience in child protection. Ms Arthurworrey said in evidence that she herself called the case when she saw it for the first time "5 out of 5 on the scale of seriousness."

It is our clear conclusion that Ms Arthurworrey did not have the requisite experience or training to be allocated a case of this complexity.

Supervision. This is the single most worrying aspect of this case from our reading of all the documents that have been presented to us and from our weighing up of all the evidence we have heard. Lord Laming says at 6.3

"Although the failing in Lisa Arthurworrey's practice were many and serious, she was badly let down by her managers and the organisation that employed her."

Mr Coppel, in his final submissions, does not quarrel with the proposition that the supervision provided by Ms Baptiste "was useless" and nor does he quarrel with the proposition that the supervision provided by Ms Mairs and Ms Kosinos "was less rigorous than it should have been."

Lord Laming is very critical of the supervision of Ms Arthurworrey (6.630-6.647). He writes: "effective supervision is the cornerstone of safe social work practice. There is no substitute for it." (6.638). He says also:

" The significance of the inadequacy of the supervision given to Ms Arthurworrey cannot be overstated. As with so many aspects of Victoria's case, the faults would have been remedied by the straightforward observance of basic practice standards. In this instance, the outcome for Victoria might have been different if her case file had ever been read by those who were supposed to be supervising Ms Arthurworrey." (6.639).

We agree with both of these observations.

The paper by Professor Nigel Parton published in Child Abuse Review vol. 13: 80-94 (2004) entitled "From Maria Colwell to Victoria Climbie: Reflections on Public Inquiries into Child Abuse a Generation Apart" (submitted to us as an annexture to Ms Davies' witness statement) summarises this aspect of Lord Laming's report by saying: "The Report argues that senior managers and others spent far too much time not taking responsibility and not appreciating the nature of the work that was going on in the 'front office'.

Mr Monaghan in his report refers also to the fact that no manager responsible for this case ever looked at or read this case file:

"They did not exercise the requirement placed upon them…to monitor and review the work. The case file was brought by LA to each of the supervision sessions. All managers had been fully informed of the necessity to read the case files…"

For us, supervision is the key. Mr Coppel poses the question in his Final Submission document: whether those shortcomings in supervision precluded the Appellant from carrying out adequately those tasks that she omitted to carry out? We have looked at all of the allegations of misconduct and we have arrived at the conclusion that either Ms Arthurworrey was given no supervision in any event and was left to her own devices, or that she was indeed told to do something which she did do in accordance with the instruction. We are unimpressed with the theory suggested by Mr Monaghan of the "baton being with Ms Arthurworrey." A more telling image would be of the most inexperienced member of the team attempting to retain a hold on an errant hot-air balloon when everyone else had lost interest. We can think of no instance throughout the entire period when Ms Arthurworrey was given real help and support from her managers. Likewise, we can think of no instance when her handling of the case had ever been criticised by a manager, and no instance of her ever attempting to conceal or dissemble any errors she may have unwittingly been making.

Office environment. The office where Ms Arthurworrey worked was not a happy place to work in during the middle and latter part of 1999. Lord Laming describes it in detail in Chapter 6, and it is not necessary to repeat this evidence here. Indeed, the Respondent does not quarrel with the proposition that the office was "chaotic". Mr Coppel submits, however, that the real question is whether that office environment precluded the Appellant from carrying out adequately those tasks that she omitted to carry out. This aspect of the matter is really part of the same question as that relating to supervision, although it goes somewhat further and raises the issue of the written guidance that was available. The manual that was used in the office was known as the DIAT (Duty Investigation and Assessment Team) procedures. This document was criticised by Ms Davies as being "worse than an owner's handbook" and that "its general inaccuracy and flavour of informality reflected local working conditions." The more detailed "Purple Book" (the Haringey Child Protection Guidelines) of 155 pages was not generally available to the team in which Ms Arthurworrey worked and was not in operation in her office. Ms Arthurworrey said in her witness statement that Ms Baptiste gave her a copy to read when she started. Ms Baptiste had told her "That is what they use in the long term team. Down here we use the DIAT one, but read through it anyway." She said that she read it and then gave it back to Ms Baptiste. Ms Davies said that this document was a far better document than the DIAT procedure book, and that by 1999 standards it was an adequate manual, although even this book had a number of omissions, especially in relation to s 47 procedures. Ms Arthurworrey said in her witness statement that she never saw a copy of the Haringey Area Child Protection Committee Handbook and she was not aware of its existence.

We have formed the opinion that the office environment was chaotic, the reference tool was totally inadequate, and that mistakes made by Ms Arthurworrey in dealing with Victoria's case must be considered within that context as well as her inexperience, lack of training and lack of any effective supervision.

We turn accordingly to consider the allegations of misconduct as set out above. We consider the specific dates together with the other work that Ms Arthurworrey had at that time, partially reconstructed from her work diary and with the benefit of some, but incomplete, information provided to the Tribunal by the Haringey Council as a result of 3^rd Party Disclosure Orders.