Learning from tragedies: clinical lessons from the Climbié report
- Editor, Archives of Disease in Childhood, BMJ Journals, BMA House, London WC1H 9JR Correspondence to: Harvey Marcovitch, Honeysuckle House, Balscote, Oxford OX15 6JW, UK; h.marcovitch@btinternet.com
Improvements in communications between healthcare workers and changes in consultant work plans are needed if we are to avoid another tragedy like that of Victoria Climbié.
In January 2001 in London, 8 year old Victoria Climbié’s great-aunt and her partner were convicted of her murder. During the last few months of her life she had come to the attention of doctors in two hospitals and social workers in two local authorities, but she remained unprotected. In consequence, the Secretary of State for Health set up an independent inquiry under a senior judge, Lord Laming. It reported in January 2003.1
Unusually, given the history of enquiries into similar cases in the UK, the prime criticism was directed not to those Lord Laming referred to as “ . . . the handful of hapless, if sometimes inexperienced, front line staff”, but to “ . . . the managers and senior members of the authorities whose task it was to ensure . . . services for children like Victoria . . .”.
The report calls for major national organisational changes: the Government has promised to respond this spring. It seeks further training for paediatricians and general practitioners which will be delegated to their Royal Colleges. Social service departments are given a list of tasks, as are National Health Service trusts. I shall deal only with the last of these.
NHS chief executives will have to complete an audit by the end of April on how they protect children. In May the Secretary of State will have the results, …
