Children's safeguarding case study: Victoria Climbié

In February 2000, a London minicab driver was called to a church in the old Rainbow Theatre on Seven Sisters Road and asked if he’d take 8 year old Victoria and her aunt to hospital as the pastor was concerned about Victoria’s state of health. Mr Salman Pinarbasi, the mini-cab driver, was so concerned about Victoria he took her to the nearby Tottenham Ambulance Station. She was then taken by ambulance to the North Middlesex Hospital and admitted. Victoria had hyperthermia, multiple organ failure, the staff could not straighten her legs and said she had injuries too numerous to record. After hours of intensive care treatment, multiple cardiac arrests and attempts to resuscitate her, she sadly died that night.

This had not been Victoria’s first visit to hospital. She had previously been taken there by an unregistered childminder who was concerned about injuries she had arrived with. These were wrongly diagnosed after admission as scabies. Victoria was also admitted on a later date as according to her aunt, she’d scalded her own head and face. After two weeks in hospital she was discharged and lived again with her aunt and her aunt’s boyfriend for the last 7 months of her life.

‘1.4 Victoria spent much of her last days, in the winter of 1999–2000, living and sleeping in a bath in an unheated bathroom, bound hand and foot inside a bin bag, lying in her own urine and faeces. It is not surprising then that towards the end of her short life, Victoria was stooped like an old lady and could walk only with great difficulty.’


Victoria Adjo Climbié (2 November 1991 – 25 February 2000) was born in Abobo, Côte d’Ivoire, and left the country with her great-aunt Marie-Thérèse Kouao, a French citizen, to be educated in France with the permission of her parents. They arrived in London in April 1999. It is not known exactly when Kouao began abusing Victoria, although it is suspected to have worsened when Kouao met and moved in with Carl Manning, who became Kouao's boyfriend. During the abuse, Victoria was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. Victoria was known to the police, social services departments of four local authorities, the National Health Service and the National Society for the Prevention of Cruelty to Children abuse. Her lack of school registration and attendance was not addressed. In what the judge in the trial following Victoria's death described as "blinding incompetence", all failed to properly investigate what was happening and little action was taken. Kouao and Manning were convicted of murder and sentenced to life imprisonment.

After Victoria's death, a public inquiry, chaired by Lord Laming, was ordered. Hundreds of witnesses were interviewed and numerous instances where Victoria could have been saved were outlined. It was noted that many of the organisations involved in her care were badly run, and that there were concerns about possible racial and cultural sensitivities surrounding the family and case, as many of the participants were black. The subsequent report by Laming made 108 recommendations related to children’s safeguarding in England. The Inquiry also prompted the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner for England.

Adults involved included:

Social workers, housing officers, police officers, church workers, her aunt, health workers, minicab driver, and an un-registered childminder.

Further reading

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