As regular readers know, I usually write upbeat articles. But this week is different. This week I don't have a happy ending for you.
I have just read the summary and recommendations of the Victoria Climbie inquiry. I read the report with a very heavy heart, at times with disbelief.
The thought of a little girl suffering so much is truly shocking.
The summary includes a chilling chronology of events leading to Victoria's death. It describes a catalogue of missed opportunities to intervene.
Senior officers are accused of not taking responsibility and frontline workers of poor professional practice.
Lord Laming puts the poor exchange of information between services at the heart of what went wrong. The lack of sharing of information contributed to no single agency being able to see the bigger picture. The exchange of essential information was often a hit-and-miss affair, with slips of paper being passed around to record key facts.
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