Every day since 25 September, Bertha and Francis Climbie have watched with great composure and dignity as a string of health and social professionals state that a mosaic of system faults may have contributed to the horrific murder of their nine-year-old daughter, Victoria.
Such is the feeling of revulsion and anger at the murder that witnesses at the public inquiry, which hopes to ensure that such a tragedy never happens again, have the haunted look of the guilty and condemned.
Last week the inquiry heard staff at the hospital where Victoria was treated for suspected 'non-accidental injuries' admit that systems to ensure proper investigation of child abuse were 'haphazard and unco-ordinated'.
The inquiry heard that doctors and nurses suspected that MarieTherese Kouao, the woman subsequently convicted of murdering Victoria, was lying about the cause of her injuries and even feared she may have abused her.One nurse made a note in the paediatric ward's critical incident log, describing the relationship between Ms Kouao and Victoria not as one of mother and child but of 'master and servant'.
But fear of 'alienating'Ms Kouao and creating an 'unco-operative'witness meant that she was not challenged with these concerns and that Victoria was subsequently discharged back into her care.
Last Thursday the inquiry heard evidence from staff at North Middlesex Hospital about the night of 24 July 1999 when Victoria, then aged eight, attended the accident and emergency ward with scald injuries to her head and face.
Ten days earlier she had been taken to Central Middlesex Hospital by the daughter of her childminder, with suspected 'non-accidental injuries'. She stayed overnight and was later diagnosed as having scabies.
On the 24 July she was seen by Dr Simone Forlee, the senior house officer in paediatrics. Dr Forlee told the inquiry that despite having completed almost 12 months in post she had little experience of child abuse cases and would have expected the consultants to take the lead.
Her first impression was that Ms Kouao's explanation that Victoria had poured hot water over her head to relieve the itching caused by scabies was 'a bit odd'. Dr Forlee said she made a 'cursory examination' of Victoria and that the burns and the past history of scabies were 'sufficient enough evidence that the child was at risk' and should be admitted.
Given the doubts about Ms Kouao, Dr Forlee said she wanted to wait for an opportunity to talk to Victoria alone accompanied by an interpreter, as it was believed that she could only speak French.
But an interpreter was never found, so the interview did not take place. It later transpired that Victoria could speak some English.
Dr Forlee was subjected to an extraordinary round of questions and answers from inquiry counsel Neil Garnham QC, about whether she could, should and subsequently did pass on vital information to social workers.
To most of these questions, Dr Forlee agreed she could and should but did not pass on information. This included vital medical details such as the fact that Victoria was limping, that the nail on her little finger was coming off, that there were lesions on her hands and dark marks on her body.
Dr Forlee said that the nature of her job meant that responsibilities changed every day and faults in the system meant that information was not passed between clinicians and social workers.
'One assumes that things were happening fairly haphazardly rather than in an organised, coordinated way, ' she said.
Dr Forlee said she did not feel she had enough experience to carry out a full examination unsupervised and that it was left to clinicians to infer from an incomplete set of 'body-map' diagrams in the notes that a full examination had not been carried out.
Inquiry chair Lord Laming said:
'From where I sit this all seems a bit hit and miss. Is that fair or unfair?' 'I suppose that is fair comment, 'Dr Forlee replied.
Lord Laming asked Dr Olutoyin Banjoko, the community paediatric registrar and Dr Forlee's immediate superior, why a detailed examination was not carried out immediately when it was vital that all evidence was collected within 24 hours of admission.
Dr Banjoko said: 'By the time we got her to the ward it was quite late. . . I felt that it wasn't morally right to subject her to a thorough examination when she was going to see Dr Rossington [the consultant] in the morning.'
Lawyers representing Haringey social workers accused nurses of discrepancies between statements at the time of the police investigation and 'what they now allege'.
'There is significant variation in the accounts of these nurses that can't be reconciled, ' counsel said.
As a result, nurses due to be giving evidence were excluded from the public gallery while colleagues were questioned.
Isobel Quinn, the senior staff nurse in duty on Rainbow ward where Victoria was admitted, said she did not believe Ms Kouao was her mother but thought that 'facts not suspicions' should be entered on medical notes. She was one of two nurses who said the relationship was one of 'master and servant' and that Victoria seemed like a 'slave'.
She described seeing Victoria sitting in a pool of urine and being shocked at the insensitivity ofMs Kouao, who sat by impassively.During her stay Ms Kouao did not bring any clean clothes for the child.
'I did not say anything to the mother because it was not my business to antagonise parents.' l The inquiry continues.Transcripts are available from www. victoria-Climbie-inquiry. org. uk