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Social workers were not attending psychosocial meetings at the hospital and hospital staff were not attending strategy meetings in social services offices so there was no forum for crucial information exchange.

Senior practitioner Rose Kozinos, who chaired the strategy meeting, did not read Victoria’s referral before it.

She had never done a case conference in Haringey, never conducted a joint 47 investigation, never undertaken a section 47 investigation when a child was in hospital, and was not memorandum trained.

She also had a caseload of 19, well over Haringey’s recommended quota, and complained she was poorly supervised.

Schwartz allowed Victoria to be discharged without investigating GP, school, or childminding arrangements, although she had assumed the latter two would be investigated by social services.

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Visits made by Kouao and Victoria to Ealing social services during spring 1999 Ealing duty social workers dealt with the case as it was seen as a housing and finance issue.Nurses also incorrectly assumed that social workers could discharge a patient.Consultant paediatrician Mary Rossiter admitted she failed to realise that what seemed a very obvious case of child abuse to her had not been comprehended by social services.The two social workers who made the visit on 14 July found nobody home but a connection was made later that day to a separate referral following Victoria’s admission to Central Middlesex Hospital.Armstrong was unable to explain why it had taken almost a month for the home visit to take place. Victoria’s admission to Central Middlesex Hospital on 14 July 1999 Staff at the hospital failed to pick up on warning signs of abuse when Victoria was brought in by Avril Cameron, the daughter of Victoria’s unregistered childminder, Priscilla.

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