How a happy little girl was turned into 'a broken wreck'

During 11 months in Britain, Victoria Climbié was "transformed from a healthy, lively and happy little girl, into a wretched and broken wreck of a human being", the official inquiry into the eight-year-old's death reported yesterday.

Lord Laming, the report's author used language that barely concealed his outrage at one of Britain's worst cases of child abuse. He said Victoria had been brought to this country for a better life and yet "ended her days the victim of almost unimaginable cruelty". She died of severe hypothermia and multiple system failure on 25 February 2000. The child's great-aunt, Marie-Thérèse Kouao, and Kouao's lover, Carl Manning, are serving life sentences for murder.

But as Lord Laming shone a light on a "gross failure" of the social services system, he said Victoria's killers were not the only ones responsible. He said he was determined the horror of the child's "lamentable" treatment by those in authority should become a "beacon pointing the way to securing the safety and well-being of all children in our society".

At the publication of his 405-page report, Lord Laming recalled the words of Neil Garnham QC, counsel to the inquiry, which heard evidence over 10 months in 2001 and 2002. Mr Garnham told the inquiry: "The food would be cold and would be given to [Victoria] on a piece of plastic while she was tied up in the bath. She would eat it like a dog, pushing her face to the plate. Except, of course that a dog is not usually tied up in a plastic bag full of its excrement. To say that Kouao and Manning treated Victoria like a dog would be wholly unfair; she was treated worse than a dog."

Lord Laming said that when Victoria was examined after her death she was found to have 128 injuries. Kouao struck the child every day with a shoe, a coat hanger, a wooden spoon or a hammer. Manning admitted beating the girl with a bicycle chain; her blood was found on his football boots.

Yet seven months earlier during a visit to hospital, Victoria had been observed as a "friendly and happy child", wearing a white dress and pink wellingtons and – as one nurse put it – "twirling up and down the ward". Lord Laming said: "Perhaps the most painful of all the distressing events of Victoria's short life in this country is that even towards the end, she might have been saved."

Unlike other incidents of child abuse that never come to the attention of the authorities, Victoria's case was "altogether different" because it was "not hidden away". The girl was in contact with officials from three housing authorities, four social services departments, two police child protection teams, the NSPCC children's charity, and two hospitals. Lord Laming said there were 12 key occasions when services had had the chance to intervene. Lord Laming, a former government chief inspector of social services, said he was amazed at the failure of key agencies to follow "relatively straightforward procedures".

Victoria, who was born in Ivory Coast on 2 November 1991, had arrived in Britain in April 1999 after Kouao promised to help her to receive a European education. Kouao, a French citizen, sought emergency housing in Ealing, west London, where officials failed to come to Victoria's help, despite noting that the scruffily dressed child looked like "an advertisement for Action Aid".

When Kouao began a relationship with Manning– after boarding a bus that he was driving – the child suffered more serious injuries. Victoria was taken by a childminder to Central Middlesex Hospital in London where a consultant, Dr Ruby Schwartz, concluded she was suffering from scabies. Lord Laming said Dr Schwartz had failed to assess the available evidence.

During a second hospital visit for a scald on Victoria's face, nurses observed bite and buckle marks on her body, but Lisa Arthurworrey, a social worker with Haringey council, and PC Karen Jones, a child protection officer, decided Victoria could safely go home. In the four months before Victoria's death, Ms Arthurworrey visited the child's home only twice and found her "smartly dressed and well cared for" even though she was clearly not attending school.

Kouao began to attend a south London church called Mission Ensemble Pour Christ, where Pastor Pascal Orome took the view that the terror-struck child's chronic incontinence was a sign that she was "possessed by an evil spirit". Manning's diary described Kouao going to the bathroom to "release Satan from her bag". When Victoria was dying, Kouao took her to the church. By the time the girl reached hospital her body temperature was 27C and she was unconscious. Staff were unable to straighten her legs.

Lord Laming said that while the treatment Victoria received from hapless frontline staff was very poor,the greatest failure rested with managers. He was infuriated by the "buck passing" of Gareth Daniel, the chief executive of Brent council, and, most of all, Gurbux Singh, the chief executive of Haringey council. At the inquiry, Mr Singh distanced himself from Haringey's failures.

The report accused Mr Singh of "hiding behind the cloak of corporate responsibility". Lord Laming said: "This inquiry saw too many examples of those in senior positions attempting to justify their work in terms of bureaucratic activity, rather than in outcomes for people."

He said he had come to understand Victoria's personality. "The more [inquiry members] heard about Victoria, the more we came to know her as a lovable child, and our hearts went out to her," he said. "However, neither Victoria's intelligence nor her lovable nature could save her. In the end she died a slow, lonely death – abandoned, unheard and unnoticed."