One of the most comprehensive and wide-ranging investigations ever into health and social services failures began last week with the opening of the public inquiry into the death of eight-year-old Victoria Climbie in February last year.
Staff from NHS trusts and social services departments in London will give evidence to the inquiry, which will seek to establish why so many people overlooked or dismissed a catalogue of injuries the girl suffered at the hands of her aunt, Marie Therese Kouao, and her boyfriend Carl Manning.
The inquiry is the first to be established under three separate statutory provisions - the NHS Act 1977, the Children Act 1989 and the Police Act 1996 - and 'will consider the actions of staff employed by a large number of public authorities and the way in which those authorities managed and co-ordinated their activities'.
The inquiry is expected to take evidence from representatives of Brent and Harrow and Enfield and Haringey health authorities, North West London Hospitals trust and North Middlesex Hospital trust in hearings between September and Christmas.
It will examine the factors that contributed to the death of Victoria, who had 128 separate injuries on her body, and make recommendations to prevent such a tragedy recurring.
Promising that the inquiry will be 'inquisitorial not adversarial', its chair, Lord Laming, said all healthcare staff who had come into contact with Victoria would be identified and assessments, diagnoses, advice and treatment examined.
The terms of reference say that the inquiry team will consider not just how NHS bodies and social services functioned, but also how they co-operated with each other.