How the Horrific Child Abuse Murder of Victoria Climbié Changed Britain’s Laws

Warning, horrific child abuse case ahead

She was just 8 years old when she crossed paths with doctors, police, churches and social workers. Yet no one saved her. By the time her suffering was uncovered, it was too late. And what investigators found would expose one of the worst child protection failures in British history. Warning, horrific child abuse case ahead. But please listen as this story needs to be heard.

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Welcome LaMs Welcome to Love and Heartbreak to Homicide, your weekly true crime podcast telling you cases of relationships that become homicides. I am your host, Ky and take a seat, take a listen all the way to the end and if you want to support each case that’s coming out, then please subscribe so you don’t miss any further cases. without further ado, I’m not gonna do my normal full episode intro because I just don’t want to in this show. So without further ado, we’re going to go ahead and get into this episode of Love and murder.

Victoria was suffering from hypothermia, multiple organ failure and severe malnutrition

On February 24, 2000 in London, England, a, uh, panicked minicab driver drove up to Tottenham ambulance station carrying an eight year old girl who was barely clinging to life. Her name was Victoria Climbié Victoria was suffering from hypothermia, multiple organ failure and severe malnutrition. She was unconscious, covered in sores, severely underweight and broken in more ways than one. Her core temperature was so low it could not be recorded on a standard thermometer. She had numerous old bruises, scars and ulcers, streaky bruises suggesting beatings and a swollen face and hands. Medical staff suspected she might have been poisoned, noting possible cigarette burns and markings indicating that she had been tied or bound. She was also unable to straighten her leg. Legs. Given the severity of her condition, attempts to Warm her were unsuccessful and the pediatric consultant, Dr. Leslie Alsford, arranged for her transfer to the intensive care unit at St. Mary’s Hospital in Paddington. Dr. Alsford, uh, described it as, quote, the worst case of child abuse and neglect I have ever seen. At St. Mary’s Hospital, Victoria’s condition continued to deteriorate with her respiratory, cardiac and renal systems failing. Despite efforts, she went into cardiac arrest and was declared dead at 3:15pm on February 25, 2000. The adults who brought her in, her great aunt Marie Therese Cawiat and Marie’s boyfriend Carl Manning, and reports said they just stood by showing a huge lack of concern. They did not care. Victoria Adjo Climbié was born on November 2, 1991 in a Bobo CTE Devroy is the Ivory Coast. She was the fifth of seven children and was raised by loving parents Berthe Amozy and Francois Climbié. She was described by her parents as a cherished member of their large loving family. In 1998, with dreams of giving her a better education in France, her parents made a difficult decision and entrusted her to her great aunt Marie, who was living in Paris. In France, Victoria started school. Her teachers noticed troubling signs during her time there. The school staff observed her sleeping through classes, which led to poor attendance. Victoria’s appearance changed, uh, drastically. Before leaving France, the headteacher noted that she saw her wearing a wig over her shaved head. French authorities recognized the risks and issued a child at risk notification that brought social workers into the case by February 1999. However, their time in Paris was brief because of issues with French authorities. And by issues, I mean that Marie was wanted by French authorities over benefit fraud. She had wrongly claimed €2,000 in child benefits. Evidence later revealed that Marie only saw Victoria as a way to claim benefits. So, afraid of getting arrested, she packed up and ran to London on April 24, 1999, dragging and Victoria with her. At first, Marie and Victoria stayed in a hostel in West London. But by May 1, 1999, they moved into a cramped apartment in Tottenham, sharing it with Marie’s new boyfriend Carl, who was a bus driver. Now, Victoria’s parents had no knowledge of their daughter’s situation. They still think that she’s over in France getting a great education and they’re happy for their daughter.

Postmortem examination of Victoria revealed 128 separate injuries following her death

Now back to the night of Victoria’s death. Following Victoria’s death, a, uh, postmortem examination by home Office pathologist Dr. Nathaniel Carey revealed 128 separate injuries and scars all over her body. Did you hear how much I said 128 separate injuries. And even he described this as, quote, the worst case of child abuse I’ve encountered. The pathologist noticed evidence of her being bound, scarred, scalded, starved and beaten. Marie was immediately arrested at the hospital on suspicion of neglect. She then had the audacity to tell the police, quote, it is terrible. I have just lost my child bit. Okay, first, you insane ass, she’s not your child. And second, you didn’t seem to have any issues or show any emotion until you were arrested. Funny how that worked, huh? Huh? A murder investigation was launched the next day. Carl was arrested at his apartment when he got home. During police interviews, both Marie and Carl claimed Victoria was possessed by demons. But Carl openly described the abuse he inflicted on her, including punching, using a shoe and beating her with a bicycle chain. They told investigators that they had taken Victoria to the local Universal Church. The pastor there then told them to call a mini cab to take her to the hospital. That’s when the cab driver, seeing Victoria’s condition, rushed her to the Tottenham ambulance station. Manning also confessed to police, saying, quote, you could beat her and she would not cry at all. She could take the beatings and pain, like, anything. Like, he was freaking proud of this and he’s telling police that, like, they should applaud. Both of them were later charged with murder. Their trial started on November 20, 2000 at, uh, the Old Bailey and lasted two months. The prosecution made it clear from the outset that blame lay not only with these two piece of crap adults that Victoria was entrusted to, but also with the child protect. Well, actually, let me roll it back. She wasn’t entrusted to those two adults. She was entrusted to her great aunt, and then the great aunt brought some other dude into the mix. So. But I digress. The prosecution also said the blame lay with child protection authorities who had been, quote, blindingly incompetent. Those two words is not something that you want to hear in a child abuse case. Blindingly incompetent. The prosecution’s case meticulously laid out the horrific abuse Victoria had suffered, showing extensive evidence of her injuries and the squalid condition where she was forced to live. They also told the court of Carl’s words to the police, where he described her ability to endure beatings and how proud he was of that. Investigators had also given the prosecution tapes, not cassette tapes, but tape, um, like duct tape, for instance, that were found in Marie’s trash that had been used to bind Victoria’s feet and wrists. Then came the information on how child protection authorities failed Victoria. Apparently, she’d crossed paths with four local authorities, two child protection police teams, two hospitals, an NSPCC center and multiple churches. Signs of abuse were noted but all failed to properly investigate and intervene effectively. Between July 1999 and February 2000, Victoria’s life became a horrifying ordeal of quote, never ending abuse and neglect. This is what was in the report. The torture she endured was unspeakable. Starvation, cigarette burns, repeated beatings with bike chains and belt buckles and hammer blows to her feet, LaMs She was forced to sleep in a black trash bag in the bathtub filled with her own excrement, burnt with cigarettes, scalded with hot water and starved. I know some of these things I keep repeating, but it’s a reason for you to understand the severity of the abuse. One concerned church member even took Victoria to a police station. But officers reportedly failed to investigate and simply returned her to Marie. A significant quote missed opportunity occurred as early as June 1999 when an anonymous call to Brent Social Services expressing concerns about Victoria’s safety was made. It was logged by Brent Social Services but faced delays and mishandling. So basically nothing happened. On July 14th, 1999 uh, the staff at Central Middlesex Hospital’s accident and emergency department examined Victoria. Dr. Rize Banan saw her at 11:50am and noticed strong signs of non accidental injuries. Then Dr. I might say this name wrong. Ekundayo Adjaye OBE did a full examination and placed Victoria under police protection with the 72 hour protection order. Then uh, in August 1999 Marie visited Ealing Social Services asking for housing help. They closed the case without a home visit. Then later doctors at North Middlesex Hospital raised concerns about belt like marks on Victoria and also said that she appeared nervous of her mother. Again, no follow up and Victoria was sent back home. Dr. Forley explained that as an on call senior House officer her role was to gather sufficient information for a child’s safety before moving on. And there wasn’t time for a comprehensive account. There wasn’t time for a comprehensive account. She also stated doctors in her position are instructed to merely record, not interpret what they are told. Staff at North Middlesex Hospital identified severe scalding to Victoria’s head. The team documented many unexplained injuries and Dr. Rossiter noted signs of neglect, emotional abuse and physical abuse. Dr. Ruby Schwartz, a consultant who they called in, diagnosed Victoria with scabies and blamed her injuries on self inflicted scratching. You heard what I said. Later it would come to light that this diagnosis turned out to be wrong. A duh. Dr. Swartz also noted in a referral that Victoria, quote, seems on edge when mom visits and, quote, jumps to attention when her mother appears. And by her mother, they’re talking about Marie, which isn’t her mother. But her guardian, Dr. Schwartz, later admitted that she made this assessment without speaking to Victoria alone. So you’re speaking to somebody who you think is being severely abused in front of the abuser. That. Is that what they teach you? Because I know for 100% sure that’s not what they teach you. Because even at doctor’s appointments, like the yearly checkup appointments for my daughter, they would ask me to leave the room, and I guess they would ask her a bunch of questions. And then I remember the first time that happened. I was like, why’d I have to leave the room? What happened? And she said, oh, they were just asking me questions about am I scared to go home, you know, um, do I feel suicidal? Stuff like that. So you’re taught to do this alone and not with the abuser right in front of. Because of course they’re going to lie to you. The abuser standing right there. But I forgot, Dr. Schwartz said she didn’t have time. What was it? Let me go back up to it, because I want to quote her on what she said. Oh, my bad. It wasn’t Dr. Schwartz who said that. It was Dr. Forley who said that her role was to gather sufficient information for a child’s safety before moving on. And there wasn’t time for a comprehensive account. That was Dr. Forley, not Dr. Schwartz. I apologize then.

Marie claimed she poured hot water over Victoria’s head because of itching

Lisa Arthur Worre, a, uh, social worker, met with Victoria on four occasions for a total of less than 30 minutes, barely speaking to her, and then claimed in her report that Victoria seemed happy. Victoria was then returned to her aunt’s apartment on August 6, 1999, after spending two weeks at North Middlesex Hospital. And then them literally not doing their job. Lisa and PC Karen Jones believed Marie’s story that she poured hot water over Victoria’s head because of itching. So you believe the story that some woman told you that I poured scalding hot water causing burns to this child head? Like, I did not know. I just did this because I thought she was itching too much. So I just poured this water over her head and you were like, sounds about right. Case closed. Johnson. Let’s go get some coffee. The ridiculous. Oh, my God. All of them are to blame. They could have saved this little girl. On November 1, 1999, uh, Marie told social workers that Carl had sexually assaulted Victoria. But the next day she said, you know what, I’m, uh, sorry, I was just mad at him. I take that back. That didn’t happen. And social worker said, okay, like, wouldn’t that even, just that, wouldn’t that even prompt you going to visit the house? Because what kind of environment. Are you serious? Lisa, remember the social worker said that she tried to visit their apartment three times between December 1999 and January 2000, but she was unable to. And she was just like, okay, well I tried. By early February 2000, Victoria’s condition had drastically deteriorated. She weighed 42 pounds, which is three stone, and was covered in sores and scars, freezing cold and riddled with infection. I mean, if they keep burning her, putting, getting open wounds on her and then making her lay in her own excrement. Yeah, infection. And then they’re taking her to the doctors and they’re just like, well, that’s Victoria’s fault because she has scabies and she keeps scratching. So maybe little Victoria stop scratching. Okay? And Victoria’s probably looking at them like, you son of a. Um, my God, poor child, poor child. She was probably cussing out all of these adults who weren’t helping her at all. On the night of February 24th, that’s when she collapsed. The pastor at the Universal Church, where, side note, Maui had dragged her for, quote, exorcism. That’s when they said, hey, can you call this minicab and take the child to a doctor? And that’s when that cab came, took one look at her and was like, yo, we’re going over here. And what ended up happening is at 3:15pm on the 25th, eight year old Victoria was pronounced dead. So when Victoria originally came in, that was like three something in the morning, right? So remember, they first went to the ambulance center and then she was sent to North Middlesex hospital. So at 3:37am Immediately after her visit, Dr. Pahari, I don’t know his first name, they never said his first name anywhere. Called Mr. Robert Philpotts, which is the out of office hours social worker for Har and J Council. Dr. Pahari told social services that Victoria had been brought to the hospital in an emergency and was critically sick, requiring transfer to St. Mary’s then he requested a follow up by a duty social worker. Ms. Hayes from the Social Services subsequently spoke to Dr. Alsfort at North Middlesex and Dr. Dillon at St. Mary’s gathering more details about Victoria’s critical state and the suspicions of poisoning, cigarette burns and being tied up. So the doctors told the social worker, meanwhile, on February 20, the same day Victoria died. Harun J. Social Services get this, closed the Victoria case with management instructions to Lisa Arthur Worre to quote, complete appropriate paperwork, then nfa. And NFA stands for no further action. So basically they’re saying, do, uh, the paperwork and we’re done. That’s it. You just got a call from a doctor that said this girl was critically sick and needed transfer to St. Mary’s they just told you about. They suspect that she was poison, they suspect this 8 year old was being tied up and they suspect she’s being burnt with cigarettes. And you said, yeah, complete the paperwork and then no further action needed. That’s what you did. Now, true to form, Marie denied all charges. Her defense hinged on the unbelievable claim that Victoria’s condition was due to the fact by what Marie says she was possessed by demons. She said she’d taken her to the church like I told y’all, to be exorcised. Because as she said, the eight year old was possessed by evil spirits. This is what she said throughout the trial. Two months of this. That’s what she said. She said, I’m innocent. She was just possessed by evil spirits. Carl, on the other hand, denied murder. He said, I didn’t have nothing to do with the murder, but pled guilty to child cruelty and manslaughter. Uh, I’m sorry, because of the child cruelty, you murdered an 8 year old. How are you going to deny a murder but plead guilty to manslaughter? I mean, I understand, like you’re just trying to get off and have like the least amount of time in jail. That’s why you would do that. But I’m sorry, sir, you pled guilty to child cruelty and that child cruelty in turn led to murder. Let’s be real with each other. His defense attempted to argue that while he accepted responsibility for injuring Victoria, he did not intend to cause her serious bodily harm. Bull frickin sit. You beat proudly, might I add an 8 year old with a bike chain. Uh, and you were proud that she wasn’t crushed. She could take a beating, man, because she. Are you. I gotta calm down because I’m getting pissed. I’m getting really angry. I could not, not be his defense lawyer because then I’ll be going to jail for aggravated assault. Because I would, uh, it would come a time where I think something in me would snap and I would leap over the table and just start beating him in the head with my binder. Like I, I couldn’t do it. Oh my God, I couldn’t do it. Oh okay, calming down now. He said that he did not intend to cause her really serious bodily harm and he certainly did not intend to kill her. In his diary, however, which was read in court, Carl referred to Victoria as what he said, Satan. That’s what he called this eight year old child. Uh, on January 12, 2001, the jury reached their verdict. If I was on that jury, as the judge is asking, if we, if we reached a verdict before he even finished, I would have jumped up. Guilty. Guilty. I’m sorry, let me sit down. Like I would have just screamed guilty. Uh, both Marie and Carl were found guilty of murder. Judge Richard Hawkins gave a statement at sentencing.

Victoria’s murder exposed catastrophic failure of child protection system in UK

What Victoria endured was truly unimaginable. She died at both your hands. A lonely, drawn out death. He then sentenced them both to life in prison. Rot, you slimy swarmy bastards. Now uh, he should go after social services and all the people that saw her case. But I know that can’t happen now. The thing about it is, even though her life was short and tragic, it did expose a catastrophic failure of the child protection system in the uk. Her murder prompted the largest review of child protection arrangement in the country. In April 2001, the government announced a public inquiry headed by Lord Lambing to investigate the circumstances surrounding her death. This inquiry was unprecedented, using special wide ranging powers to scrutinize the roles of social services, police and health authorities. And I hope by the end of this inquiry, everybody who touched a paper, a uh, phone, anything dealing with this little girl was fired. I really hope so. Lloyd Lammon’s report published in January 2003 detailed a, quote, widespread organizational mallees and lack of good practice within the agencies that had contact with Victoria resulted in a quote, lamentable failure to protect her. The report highlighted numerous missed opportunities and communication breakdowns between uh, different agencies. Several witnesses gave significant evidence. Dawn Green, the child Protector Advisor for HAR&J Social Services, was shocked by serious protection failure at the North Tottenham office. Edward Armstrong, senior Brent social worker, revealed how senior managers pushed to close dozens of vulnerable children’s cases inappropriately. It was just a closing numbers. We got to push those numbers. We got to have high closing numbers. Dr. Schwartz admitted she failed to write a discharge letter, among other procedural mistakes. I mean, to say the least. I guess PC Karen Jones didn’t investigate Victoria’s injuries after she believed Mali’s stories about self infliction. I mean the final report listed agencies had quote, blindingly incompetent practices, which is literally what the one of the lawyers said in the case. The prosecution information Was quote, lost due to slips of paper. Slips of paper, Slips of paper. Were y’all writing this on napkins while you were eating your lunch? Managers failed to oversee even the most basic procedures. Councils that lacked staff and good management, low priority given to child protection, not enough funding and poor leadership in all departments. Lord Lamon, uh, found an absence of basic good practice and noted the failure of senior positions to ensure proper service delivery. He argued for a clear line of accountability from top to bottom, without doubt or ambiguity about who is responsible at every level for the well being of. In response to the communication failures, the two hospital consultants who cared for Victoria stated. I cannot account for the way other people interpreted what I said. Uh, I’m sorry, my mouth was wide open. Wow. I’m going to repeat that quote. I cannot account for the way other people interpreted what I said. It was not the way I would have liked for it to have been interpreted. That was a quote by Dr. Schwartz and also another quote quote, I do not think it was until I have read and reread this letter that I appreciated quite the depths of misunderstanding. Wow. Another. My jar M is on the ground. That was a quote by Dr. Mary Rossiter. So they’re pushing the blame of other people. You didn’t understand what I was saying, so I can’t help how you interpreted what I read. I clearly said she was being abused and you interpreted it as something else. Uh, I’m, I’m, I’m shocked. I’m shocked. I’m sorry. Y’all are going to have to bear with me because I need to go back through my notes and see what Dr. Uh, Schwartz said and if there’s anything from Dr. Rossiter that I have in my notes to see how anybody clearly misinterpreted what they said.

Dr. Schwartz diagnosed Victoria with scabies and blamed her injuries on self inflicted scratches

Okay, so let’s go through Dr. Schwartz notes. Now according to reports, I’m not the one making this up, so nobody come for me. You want to see all my sources? They are listed on my website, murderinlove.com. so according to reports, Dr. Schwartz diagnosed Victoria with scabies and blamed her injuries on self inflicted scratches. So she’s saying it’s not my fault. You misinterpreted that I diagnosed her with scabies and blamed her injuries on self inflicted scratch. I mean, I don’t understand how else I’m supposed to interpret that, but my bad. I guess I should have said after you said it was scabies. I should have then thought that meant, oh, she was being abused and her injuries on self inflicted scratching I should have thought. Thought that meant that her parents were burning her and beating her with bike chains. My bad. She did put in there that Victoria, quote, seemed on edge when mom visits and quote, jumps to attention when her mom appears. But she also later admitted that she made this entire assessment without privately speaking to Victoria. So she didn’t follow the chain of, uh, command or whatever you’re supposed to do when you’re dealing with abuse victims. But that’s the quote you came out with. Okay, LaMs, I’m sorry. I had to then do a deep dive into everything Dr. Schwartz said. So I went back to my notes. This is gonna make this episode a little bit longer. But I really had to go back and do a deep dive. Cause I couldn’t believe. So I’m gonna bring out. It’s not gonna. This part is not gonna be in like the story mode that I usually do. This part is just gonna be like notes. And I’m gonna bring out everything that Dr. Schwartz said in all of the reports. So let’s go through it together. So Dr. Schwartz said, quote, uh, I feel devastated and saddened that we failed to protect her and I was not more proactive in doing things. This was a quote that she said in, uh, regards to her role in the outcome of Victoria’s death. Regarding the inquiry on Friday, October 12, Dr. Schwartz admitted that she was, quote, responsible for a series of procedural failures in Victoria’s treatment which saw the girl return to her abusers. These failures included, quote, failing to write a discharge letter and delegating the social services referral letter to a locum senior house officer who stated there were no child protection concerns about the eight year old’s case. Continuing on in the inquiry, when Dr. Obig called her to report a child with suspected non accidental injuries, Dr. Schwartz recalled that her response was to, quote, direct Dr. Ajayi OBE to admit Victoria and advise social services of the position. She said that she would come and see the child later that day. Then after she saw the child, they asked her about the examination of Victoria. And Dr. Schwartz said that she left the child’s examination for her last examination of the day because her case was a, quote, complicated one and she wanted sufficient time. And she said during her discussion with Marie who explained Victoria’s injuries to her. So it was Marie who said these were her injuries. Dr. Schwartz regarded the explanation as, quote, plausible. And when in this inquiry they asked her about her scabies diagnosis, Dr. Schwartz said that, quote, what I found were the marks, particularly on her hands, the scratch marks, the Areas that looked as if they had pus in, and the fact that there were scratches on the body as well. She said she was influenced by the resemblance to past scabies cases. Regarding Dr. Ajayi Obeyed’s suspicion of physical abuse, Dr. Schwartz said that in her judgment, quote, neither the quantity nor the distribution of the marks on Victoria’s body were indicative of physical abuse. Quantity? Or is it a certain quantity or distribution of the marks that turns into suspicion of physical abuse? Like what? She also thought the hand marks looked like, quote, superficial scratches rather than cuts inflicted by a razor blade, and saw nothing significantly abnormal about Victoria’s eyes. She also reported that she couldn’t remember looking at Victoria’s fingernails or asking Victoria if she scratched herself and found no evidence of scabies. Burrows. Dr. Schwartz accepted that Escaby’s, uh, diagnosis couldn’t account for all the marks, but felt the others, quote, could have been old insect bites. Some of them could have been secondary to knocks that she had sustained during the course of play and movement around. Some of them could have been things that could have occurred prior to her coming to this country. I did not feel that they had the configuration that would worry me of a child that had suffered non accidental injury. Keep in mind, lambs, this child was being hammered in the feet, burned, scalded, beat with a freaking bike chain. Are you serious right now? In her evidence, Dr. Schwartz was, quote, unshakable in her conviction that Victoria had scabies. She also said, uh, she was clear that in her judgment, Victoria was, quote, not exhibiting signs of physical abuse. When she saw her during oral evidence, she admitted she, quote, could not entirely exclude physical abuse. So which one is it? You said she wasn’t exhibiting signs of physical abuse, but then when you gave this oral testimony, you couldn’t entirely exclude physical abuse. Wow. But the tenor of her evidence was that there was very little, if any, visible indication of abuse. Legs were being beaten by a hammer. I. Okay. She also went back. So again, remember, I’m not. I’m reading this as notes. So it’s going to go back and forth and back and forth and I’m probably going to be repeating things. She also said that the lesions compatible with scabies scratchings were, quote, predominantly on her hands and arms. She said she had been influenced in her diagnosis by the fact that Victoria had lived in, quote, poor conditions in the Ivory Coast. Are you serious? Now you’re blaming her country, saying that she, quote, had lived in poor conditions? I had been informed that she had come from abroad, that she May have had marks from insect bites or the like abroad. Wow. So you’re just like, oh, well, she’s not from here. So clearly this is how all kids must look into Ivory Coast. So we’ll, uh, say scabies, because, you know, Ivory coast scabies. I mean, that’s what I can come up with. So check, check and check. Wow. She’s blaming abroad now. That’s. That’s freaking crazy. And clearly I was not saying that people from Ivory coast have scabies or anything like that. I’m just trying to see this woman’s mindset, which. Her mindset, it was. She was from abroad. So this is what it could have been. And that’s it. She didn’t question it, she didn’t investigate nothing. Just. That’s it. She came from the Ivory Coast.

Dr. Schwartz said she should have gone through each of Victoria’s injuries

Oh, okay, then, uh, in the inquiry, Dr. Schwartz said that she was, quote, almost positive that she had spoken to someone from Social Services that morning about her concerns for Victoria and that possibly she had spoken to M. Ms. Hines. But I’m not sure. I’m positively, almost sure that I possibly spoke with someone. Maybe. Almost definitely for sure. And it was possibly Ms. Hines, certainly. But maybe Dr. Swartz said she should have gone through each of Victoria’s injuries and asked Marie for an explanation, but admitted that she possibly did not. You know, I take so many of these cases that I can’t even remember I did. Maybe I didn’t. Who knows? She came from the Ivory Coast. She said that although Dr. Ajayi Obey had, um, left a message, she didn’t get to speak with them because they had gone off duty. And she said that her normal practice was to write her own notes, particularly in complicated cases like Victoria. And her failure to do so was likely due to being called away urgently. Yeah, doctors get called away urgently all the time. But then it’s your responsibility to come back and write your notes. Like I’ve worked for doctors, they will stay up all night writing notes that they didn’t get to the whole day because they were busy the whole day. They don’t get sleep. They work all the time. Like, even when they’re home, they’re writing notes. On their off days, they’re writing notes. They have to write your notes. So that’s not an excuse. I know a bunch of doctors who get called away urgently, and they still get their notes done. Regarding the notes taken by a, uh, Dr. Modi, Dr. Schwartz said that they did not reflect the totality of what took place during the course of her examination. And Assessment of Victoria in particular, they didn’t reflect that although she ruled out non accidental injury, she was still concerned Victoria might be suffering, quote, other forms of abuse. She stated that in light of subsequent events, quote, it was a disaster from her point of view that they did not. Okay, so basically what I’m asserting from this is that Dr. Schwartz didn’t write her own notes. As she said with cases such as this, she gave the task to Dr. Modi, so handed it off who Dr. Modi possibly wasn’t in the room. I’m not going to say was or wasn’t, because I don’t know, but possibly wasn’t. She just transcribed what happened to Dr. Modi, and then now she’s blaming Dr. Modi for Dr. Modi not putting everything into notes. Craziness. Dr. Schwartz asserted that oversights like the failure to perform a skin swab or obtain a, uh, dermatology opinion, quote, cannot be prevented. Oh, my God. Stating, quote, there are many requests that in this case and in other cases we ask for that do not appear or occur. I do not know, in a system where there are so many people, how we can actually prevent these sort of things from occurring. I just, I have no words for that. So basically, she diagnosed scabies on site, didn’t do a skin swab, and didn’t send her to a dermatologist, just scabies, and say, well, I don’t know how to prevent this from happening in the future because, you know, there’s so many people in our system. I mean, this is bound to happen again. How? I don’t know how we can prevent things like this from happening. I mean, I’m not in medicine, but I’m pretty sure systems are in place for a reason. Um, if it’s dealing with skin, you refer to a dermatologist, like, literally, the way to prevent these things from happening, even though there’s so many people in your system, is just following the chain of command. Literally. That’s it. Or is it just me? Because I’m. Like I said, I’m not in medicine. Maybe I’m just thinking my, my degree is in it. So maybe because of that, I’m just talking out my ass. So if you’re in medicine, let me know. Maybe I’m talking out my ass. I don’t want to say anything. It’s not my department. For her part, uh, Dr. Schwartz remembers being paged by Dr. Dempster on the morning of July 15th and being told by her that social services were, quote, not investigating further. So I guess what she shrugged her shoulders and said, okay, but I mean, you even said that you didn’t think this was abuse, you thought it was scabies. So I don’t know. Anyways, having received this news, Dr. Schwartz was, quote, almost positive that she spoke to someone in Social Services seeking an assurance that Victoria would not go home without being satisfied with the, quote, significant worries, uh, she felt about her would be addressed. These included housing and schooling concerns. Dr. Schwartz said that the writing of the letter to Social Services should not have been left to a locum doctor with little knowledge of the case, and that had she written it herself, its contents and emphasis would have been very different. She regarded Dr. Dempster’s letter as only a very, quote, superficial account of the complex discussion. So basically you’re saying if you wrote it yourself, then you would have gone more in depth and you shouldn’t have left the writing of the notes to Dr. Dempster, who gave a superficial account of the complex discussion. So I think this is just her attempt at taking responsibility for her failure. I guess hindsight is 50, 50, uh, 20, 20, whatever it is. That’s literally what she said in a nutshell. Dr. Schwartz did accept that she should have arranged some form of medical follow up for Victoria prior to her discharge, blaming pressure of time and the lack of a, quote, fail safe mechanism. Dr. Schwartz’s assessment was that the lack of recording the identity of the person who decided to discharge a child was a, quote, worrying state of affairs. Dr. Schwartz told the inquiry she assumed Social Services would investigate further after her examination. But I thought you also said that you got a report that Social Services said they weren’t investigating, uh, further. In dealing with a conversation with PC Duear, it’s likely that a summary of Dr. Schwartz’s views given to the police constable were, quote, incomplete, and that Dr. Schwartz had, quote, some lingering concerns about Victoria, that she expected to be followed up by Social Services. But again, you said you received noticed that Social Services was going to. Wasn’t going to follow up. I, uh, these are conflicting quotes. Like, is it just me? First you’re like, yeah. Then you’re like, no. Then you’re like, I thought social services. Then you’re like, I was told Social Services wouldn’t like. She also said if questioned more closely, quote, it would have become clear that she had not satisfactorily accounted for all of the marks that had been noted on Victoria’s body, so that physical harm remained a possibility. You said scabies. Dr. Uh, Schwarz told the inquiry she had, quote, never before viewed deliberate harm as a disease process or entity and thus had never approached its management in the same manner as other childhood ailments with which she would commonly have to deal. However, she thought that there was merit in such an approach. Then at the end, Dr. Swartz stated, quote, I cannot account for the way other people interpreted what I said. It was not the way I would have liked for it to have been interpreted. I’m sorry, LaMs I had to do that little deep dive because I, I, I couldn’t believe that quote. And apparently, wow, I don’t know. Let me know what you thought about that. Up and down. You heard all my notes again. You just heard the raw form of my notes.

Mary said that Dr. Schwartz put blame on everyone for the tragedy

Let me know what you thought about that. And I’m not even going to go into the deep dive of what Dr. Mary said. I’m just, uh, not m even going to do that. I mean, the deep dive into Dr. Schwartz was enough for my head. I have a headache because it’s just sad. I guess she was trying to take account for her role in it, but also, it seemed like she was also pushing the blame onto everything else. You know what I’m saying? That’s what I got from all of that.

Lord Lamon argued bad practice was extremely costly and that proper procedures were followed

Anyway, back to the case. Har&J Council also reported that it couldn’t assign social workers to 109 children. In May 1999, 109 children were not assigned social workers. This was right before they took on Victoria’s case. So they were already backlogged by 109 children. Brett Council’s chief executive later admitted that social services department was, quote, seriously defective. Lord Lamon emphasized that, quote, information systems that depend on the random passing of, uh, slips of paper have no place in modern services. That’s what I say. Remember I said slips of paper. What are you doing writing this on a napkin? Like, why are you writing anything on paper? While many commentators, uh, focused on lack of resources, Lord Lamon argued that bad practice was extremely costly and that had proper procedures been followed, the necessary expenses would have been less. However, some, like Brent Council representatives acknowledged that children’s social work was underfunded. In all, Lord Lamon identified 12 key opportunities where Victoria could have been saved. There were no fewer than 12 key occasions when the relevant services had the opportunity to successfully intervene in the life of Victoria. Medical record keeping at hospitals also came to light. In this case, a study showed that 94% of clinicians needed to create detailed and timely notes. 94. But at the same time, uh, you have one doctor writing notes, and like unlike, um, Dr. Schwartz said, I have to agree with her on this. If an emergency happens, which usually happens to doctors, they have to run out. They can’t write notes. So how do we rectify this? I mean, we could have two doctors there, or we could have a doctor and a nurse. The nurse to take the notes and write the notes and the doctor will read over the notes. But then, as expensive as going to the doctor is, already that’s going to become more expensive, because then you’re going to have a doctor and a nurse and whoever else for one patient. That’s a lot of expenses because everybody has to be paid and you can’t really expect a doctor to work 24, 7. But then again, I actually just thought of an idea to combat this, but I don’t want to put it on air because it could be actually a revolutionary idea. I got to run it past some people.

Audit finds gaps in how NHS trusts handle child protection documents

All right. Continuing with the reports, the audit discovered significant gaps in how NHS trusts handles their documents. Children’s medical records were not kept in one place by hospitals, which made communication between departments difficult. Staff needed to properly document clinical discussions and phone calls about child protection. In about 85% of cases, written statements to social services became mandatory when child protection was suspended. Expected. Lord Lamon wrote that, quote, none of these interventions would have required great skill or made heavy demands on staff. Sometimes it needed nothing more than a manager doing their job by asking pertinent questions or taking the trouble to look in a case file. There. There can be no excuse for such sloppy and unprofessional performance. But I’m going to say, in this case summit, I could understand where something fell between the cracks. I can understand that in some situations, like doctors, they do get called away a lot. However, there is no excuse. You do need to get your notes in. In terms of stuff, uh, being written down on paper, that’s freaking crazy. Records not being in kept records not being kept in one place in the hospital, records not being shared across board, that’s freaking crazy. But expecting, for instance, a doctor to write their notes immediately, that’s not always going to happen, because what are you going to do? They got a code blue and they’re going to say, wait a second, I have to finish writing these notes. This person is just going to have to wait, like, you know what I’m saying? Some issues like that I can understand. The inquiry led to 108 recommendations for change. Lord Lammond considered the most important to be the development of a national agency for children and families with powers to ensure other Agencies fulfill their responsibilities. Again, that takes money, that takes hiring people, that takes hiring competent people. So still, recommendations included ensuring social workers conducting Section 48 inquiries are trained and that there are six monthly reviews of temporary promotions. So if somebody’s promoted they need six monthly reviews. He stressed that recommendations will work only with professional and managerial commitment. The need for improved training, supervision and interagency communication was paramount and most importantly, a national emphasis on putting the needs of children first, not bureaucracy. Is that ever going to happen? Lord Lamon put in his report that no more than a summary of what was heard can neither rehearse nor condense the vast amount of the evidence that was put before me. The investigation led to major changes in how medical staff were trained. The numbers were concerning. Only 29% of hospital staff who dealt with child protection cases went through revalidation for child protection and harm assessment. The situation was similar with community services. There were just 55% of hospital staff who received specific child protection training. The Royal College of Pediatrics and Child Health implemented new resources like the Child Protection Handbook for medical professionals, advanced training courses in partnerships with Advanced Life Support Group and standardized packages for trainee doctors. Senior doctors had to fully examine 98% of child protection cases within 24 hours after admission. The court team made sure 77% of suspected cases got clearance from senior doctors before discharge. Documentation of follow up plans at discharge became necessary for 78% of cases. In 2003 the Department of Health then launched the Every Child Matters program. This program created a new framework to protect children. This program wanted uh to achieve the five most important outcomes for children. Staying safe, being healthy, enjoying and achieving, making a positive contribution and achieving economic well being. The Victoria case also led directly to the Children act of 2004 which brought major changes to England’s child protection laws. This new legislation created unprecedented safeguarding measures that focused on making agencies more accountable and promoted child welfare. Then in uh, 2025 the children’s well Being and Schools bill made m this requirement even stronger in this local authorities must keep registers of children not in school. Councils can now gather more information about children’s education status, including their name, addresses and educational arrangements. Which is good because a lot of people who want to abuse their children do just take them out of school. Victoria’s parents said they hoped her death quote would not be in vain, which apparently it wasn’t because it did lead to a lot of reform, uh, in the social services area, in the hospitals and stuff like that. So them calling for real change so that no other child will suffer. Like their daughter did, seems to be taking effect, unfortunately. And sadly, that it had to start with Victoria. But also, 25 years later, the question still stands. Have we as a whole, the world, not just England, even the United States, truly learned anything? I’m, um, literally still doing cases of child abuse that fell between the cracks. And usually they cite short staff overwork, you know, the usual, as excuses. So my question is, how can we fix the problems of being short staffed when it comes to dealing with children? But also, maybe these people don’t want to work in these sectors because many times their hands are being tied and they end up seeing the same abuse victims go unhelped and the abusers walk out of their offices with smiles of triumph on their faces. And that is not even from cases that I’ve done. That is real life instances that I’ve heard from friends who used to work in these sectors and they quit working in these sectors because of situations like this. You know, I think I told y’all of a story. One of my friends from high schools, their dream was to become a lawyer. Throughout the whole high school, that’s all this person ever said. They finally became a lawyer. They became a lawyer for children, a child advocate lawyer. And they ended up having to quit because of loopholes in the law and this and this with the law. They kept seeing the child go back to abusers. And one of these abusers did turn around and smile like, uh, you, you’re not going to win this. You’re not going to do anything. This is my fan. Like, you know what I’m saying? They show this on Law and Order. You think it’s just tv. They have to get this content from somewhere. And now I’m not saying this is the only issue because there are lazy people and there are people in the profession just for the paycheck. Like, literally they could give a, uh, damn. They’re just there to get paid and paid their bills and so many other issues. So my question is, how do we resolve this? Every time a vulnerable child slips through the cracks, it feels like we haven’t done enough. And Victoria is an example of a child who was failed by the very systems who were meant to protect her. Yes, there are some changes going along, but I bet you right now I can find you a case in 2025 of a child abuse victim that still has the same issues that Victoria did. But it’s on all of us to make sure that her death was not in vain. And the words never again actually mean something. So how should we go about doing this. This is the question. If you suspect, uh, child abuse, call the Child Help National Child abuse hotline at 1-800-FOR CHILD, or 1-800-422-4453, or you can go to childhelp.org all calls are toll free and confidential, and the hotline is available 24. 7 in more than 170 languages. Today’s case was another reminder of why Child Abuse Prevention Month matters. If you learned something, felt something, or just need to talk about it, share this episode, Keep the conversation going and keep Victoria’s story being told, because this might help a child in need.

DJ: Why do I shout out my Patreon? This is my job

And that is all I have for you today. I know this episode was longer than it normally is, and I know you went through some case notes with me, and I know you went through it with me and your emotions, like, ugh, uh, I couldn’t even. So thank you so much for joining me. Thank you for being a supporter of Love and Murder. Thank you for your time. And, uh, as I remind you, at the end of every full episode, it’s say it with me now. All love and no murder. Y’all Bye.

Carissa Jane Smith is accused of having sex with multiple Missouri schoolchildren

rape, sodomy, sex trafficking of a child, and sexual contact and misconduct with a student. Uh, look at her dumb face. I’m sorry, she. I just don’t like her face because of what she did. Smith was a paraprofessional and longtime substitute teacher in the Dixon School District in Missouri, about 130 miles southwest of St. Louis. Before her arrest, she’s accused of having sex with at least two students. One victim told police that it all started in August 23rd when he was in middle school. The victim said he met Smith while she was substituting for his class, and she gave students her Snapchat username. According to police documents, quote, Smith, Smith began sending them pictures of her breasts and buttocks along with her nude in the shower. What is wrong with you? You couldn’t find a man your age? Oh, my God. Okay. Cops say she had sex with the students at her home and other locations include gravel roads, multiple times over the course of a year. She allegedly gave the students money, alcohol and marijuana and told them to keep their mouth shut or they’d get in trouble. No, you, uh, would get in trouble. You would get in trouble. Not them. The things these people, you know, that’s one thing I had to tell my child is if somebody says that you’re going to get in trouble or they’ll kill your mom or any of the other cliche stuff that these people say, I said, do not believe them. Come and tell me and we’ll face whatever happens together. But I had to go down the list of stuff that I’ve heard people would tell a child to kind of coerce them not to tell an adult. I said don’t listen to them. Say yes in their face, but don’t listen to them. You immediately come and tell your mother. Hear the full episode and more by joining our Patreon patreon.com forward/loveandmurder.