"Lessons haven't been learned"

Some days, you feel lifted up by demonstrations of fellow humanity all around. Other days, parts of that same humanity can leaving you feeling as if you've been taken to the edge of the pit of Hell and made to look over.

A little over a week ago the 23-year-old mother of a four-year-old girl, and her partner who is 27, were sentenced to 10 and 11 years respectively for the most horrific abuse of the child, who suffers from cerebral palsy. Readers of a sensitive nature may wish to skip over the details to the next paragraph. The systematic violence they subjected the girl to included pouring boiling water over her hands, ripping clumps of hair from her scalp, repeatedly kicking her in the groin and locking her naked in the lavatory every night, sometimes forcing her to eat her own faeces. When she was finally rescued, at the insistence of her grandmother who noticed she was in constant pain, she had to be examined under general anaesthetic. The kickings she received have resulted in permanent liver damage.

Social workers had previously allowed her to return to the "care" of her mother despite strong objections from her foster carers. Once she was home, these same social workers were said to have 'too readily' accepted injuries (including a broken arm) as accidents, and made 'minimal contact' with the father. When attempting to visit the child to check on her welfare, on five consecutive occasions they believed the mother's story that the child was "out with her Dad.".

The case has alarming parallels with the infamous story of Victoria Climbié, the eight-year-old who was tortured in 2000 and who eventually died as a result of her injuries. Campaigners who worked hard to change the system at that time are horrified by this latest incident and incredulous that it can still be happening.

Sadly, I'm not incredulous. The same old platitudes are trotted out every time we hear details of these sickening cases. "Lessons must be learned," they say. Actually someone in a position of authority was finally too embarrassed to use that phrase this time. Instead they said "lessons haven't been learned." No, they patently haven't. But why do these lessons have to wait until after a child is dead, or permanently injured? Have these people never heard of training? There is a mountain of casework on file about abused children. A mass of research into things to look for.

Will anyone be fired? I doubt it. There's been an inquiry, there will be recommendations, a public wringing of hands and declarations of anguish and regret. But what will really change? OK, there are civil liberties issues. I realise you can't go marching into people's homes with no notice, and in the majority of cases there isn't anything untoward going on. Hard cases make bad law, etc, etc.

But for me, this comes back to being all about process. In its most basic sense it's exactly like the Bernard Mathews case where ordinary workers do not follow established processes. Processes that are written by experts, often as a direct result of previous public enquiries or their recommendations, but which cause extra work for already overstretched staff and therefore are skirted around or simply ignored at the coalface. Social workers are lulled into believing they are unnecessary because in the majority of cases there is no abuse going on, so there is no untoward effect of not following process. But the process is designed to catch the 0.1% of cases where there IS abuse. And to work, it has to be followed 100% of the time. It has to be second nature. And it needs to adapt to emerging patterns of abuse.

Abuse like this is systematic. It goes on for months, often years. Alarm bells should be sounded on the second or third visit when a child is missing or "unavailable." A rule like "three strikes and you're out" would seem fair to me. After three missed visits, a warrant should be granted to enter the home without notice and check on the child. How many more will die before this mess is sorted out?