The focus of this week’s newsletter is Maria Colwell, whose tragic death lead to major changes in child protection in this country. The story of Maria was a watershed moment in child welfare in the UK; she has remained in collective memory and has often been referred to when similar and much more recent cases of have come to light, such as the death of Victoria Climbié in 2000, Peter Connelly in 2007 and Daniel Pelka in 2012.
Maria Colwell was born in Hove, near Brighton, on the south coast of England on 25 March 1965. She was born the fifth child of Raymond and Pauline Colwell. Her father died when she was just four months old, and in these difficult circumstances, Maria came to be looked after informally by Raymond’s sister, Doris Cooper, and her husband. Some 10 months later, still as a baby, Maria spent an unsatisfactory period of less than seven days back in the care of her mother. Pauline Colwell’s short resumption of the care of Maria coincided with her expressed intention to set up home with a man called William Kepple, with whom she had quickly begun a relationship and would marry in May 1972. However, on application by the County Council in August 1966, Maria was made the subject of a Fit Person Order (broadly equivalent to a care order today) and returned to the now formal foster care of the Coopers. By all accounts, the Coopers loved Maria. She had become an inseparable play friend of two of the Coopers’ grandchildren and she was taken on holiday trips to Newquay, Blackpool and Longleat. The Cooper family snaps all include a smiling Maria. But Pauline was determined to regain custody of Maria. Eventually in October 1971, social services, guided by the notion of the birth mother’s rights and her ‘blood tie’ to the child, placed Maria in the care of her mother and stepfather. Maria was observed weeping, kicking and screaming as she was taken from her foster home.
Maria was starved and beaten in her new home and suffered from cruel emotional abuse over the next 15 months. William Kepple had children of his own with Pauline, and the couple favoured those children over Maria. For example, Kepple bought his biological children ice cream and required Maria to watch as they ate it, having refused to buy any for her. She was locked in her bedroom for long periods of time while the rest of the family would eat together. Maria was described as ‘almost a walking skeleton’ and was spotted rummaging for food from bins. Despite the fact that many neighbours and teachers communicated their concerns to various agencies, and the fact that she was actually under the supervision of both the local authority and the National Society for the Prevention of Cruelty to Children (NSPCC), and the fact that the home was visited on over 50 separate occasions by a variety of safeguarding professionals, including her named social worker, nothing changed.
On the night of Saturday, 6 January 1973, William Kepple came in at 11.30 pm to find Maria watching television. Maria’s mother, fearing her drunk and violent husband, had kept Maria up. Maria refused to acknowledge him upon his return home, and he responded violently. He repeatedly kicked her, leaving her with severe injuries both internal and external; then he went to bed (investigations later concluded that it was impossible to ascertain the precise circumstances surrounding the days preceding Maria’s death, particularly given the conflicting and confused evidence provided by William and Pauline Kepple). Despite obvious signs of distress, no decision was taken to have Maria seen by a doctor. The following morning William Kepple wheeled Maria in a pram to the Royal Sussex County Hospital in Brighton with severe internal injuries including brain damage; she died shortly after arrival. Maria had an empty stomach when she died. Both her eyes were blackened, and she had a fractured rib. She was seven years old.
On post-mortem examination, the majority of the injuries found on Maria’s body, described by the pathologist in the case as ‘the worst he had ever seen’, were judged to have resulted from ‘extreme violence’. William Kepple was convicted of Maria’s murder in April 1973, although, on appeal, the charge was reduced to manslaughter and he was sentenced to four years. All Maria’s siblings and half siblings were taken into care.
The case caused local outrage, and a strong campaign for justice for Maria soon drew national interest. People were concerned that Maria had been removed from a caring home against her best interests. So many referrals made about her welfare by the local community had been ignored. Other warning signs recorded by professionals on their many visits to the home, including several instances of physical injury such as bruising, had never been followed up.
In 1974 a publicly funded formal inquiry into the death of Maria Colwell was set up to investigate the circumstances of her death. With no precedent for such an inquiry, it took the form of a quasi-judicial hearing, meaning that witnesses appeared voluntarily and were open to cross-examination by both defence and prosecution. Following a preliminary hearing on 24 August 1973, there were 41 days of public hearings between 9 October and 7 December 1973, where the inquiry heard 70 witnesses, received 13 written submissions, and examined 99 documents. The inquiry gained widespread media coverage and public attention and was significant in bringing awareness of child protection issues to social and political arenas. The format set by the inquiry also established a pattern replicated in following inquiries over the next quarter of a century. Maria’s death had set the precedent for a public interest in children’s safeguarding.
The Report of the Committee of Inquiry into the Care and Supervision Provided in Relation to Maria Colwell identified three main contributory factors:
- the lack of communication between the agencies who were aware of her vulnerable situation.
- inadequate training and support for social workers assigned to at-risk children; and
- changes in the make-up of society.
The greatest failure was deemed the lack – or ineffectiveness – of communication and liaison between the agencies involved; information was not being passed on and there was no proper co-ordination. Maria’s social worker, an inspector from the NSPCC, and Maria’s family doctor were criticised for missing concerns raised by Maria’s neighbours and schools. Despite the 50 official visits to the family, there was poor recording, a lack of information sharing, and a lack of any collation of case history.
Secondly, the individual social worker involved was severely censured for her lack of knowledge and what was seen as a series of mistaken decisions. Training was therefore an issue as was the proper knowledge of what the then existing legislation would permit. The difficulties of social workers experienced of having to make decisions under time pressure and with limited resources was also acknowledged.
Lastly, the inquiry partly blamed society for the death of Maria Colwell. “It is not enough for the State as representing society to assume responsibility for those such as Maria”. The inquiry report’s conclusion suggested that the ‘highly emotional and angry reaction of the public in this case may indicate society’s troubled conscience’, suggesting a vision of broader public responsibility for child protection.
The public inquiry report also represented an early attempt to understand the perspectives of young children in safeguarding practice, in other words, to listen to the Voice of the Child. The report argued that ‘even very small children possess sometimes a remarkable acuity as to the implications of both situations and conversations which adults ignore at their peril’. The report found that statutory agencies had expressed some interest in Maria’s feelings. Markedly though they drew their conclusions by observing her emotional states—whether Maria was ‘happy’, ‘outgoing’, or ‘subdued’ – or by observing her physical behaviours, for example, repeatedly running away from visits with her biological mother, and showing ‘strenuous’ resistance by ‘kicking and screaming’. Her social worker had told the inquiry that she had had to make ‘an intelligent guess as to Maria’s true feelings’. Why not ask Maria directly? The report illustrates how much our accepted practice in regard to child centred safeguarding has progressed in recent years.
The inquiry into death of Maria Colwell created a watershed moment in children’s safeguarding procedures in this country. It directly led to the creation of the three pillars of today’s system: area child protection committees to offer cohesive local leadership in safeguarding (now safeguarding partnerships), inter-agency child protection conferences to consider specific cases and risks, and child protection registers to identify children at risk (the precursor to today’s child protection plans). Furthermore, her death changed the direction of social work in this country. Before Maria, social workers had regarded the family as the primary mechanism for ensuring the welfare of children, with social workers entrusted with the key responsibility for state child welfare. After her death, child protection processes focussed on the family unit in particular as a site of possible abuse and intervention.
Over 50 years on, the recommendations of the Maria Colwell Inquiry still have a resonance and clarity all too relevant today. Maria remains the reference point for all subsequent child abuse scandals. Every member of the children’s workforce should remember the lessons learned from her tragic – and clearly preventable – death. If you are interested in finding out more about the safeguarding awareness training I deliver, where we learn the lessons of the past, please do not hesitate to contact me.