Committee of Inquiry into the Care and Supervision Provided in Relation to Maria Colwell (1974) Report of the Committee of Inquiry into the Care and Supervision provided by local authorities and other agencies in Relation to Maria Colwell and the co-ordination between them (Chairman: T.G. Field-Fisher) London: Her Majesty’s Stationery Office 0 11 320596
Coming so soon after the establishment of Social Services Departments and the encouragement to local authorities from the then Secretary of State, Sir Keith Joseph, to develop a strategic approach to delivering services, the death of Maria Colwell at the hands of her step-father while under the supervision of East Sussex County Council sent shock waves through the social work profession from which it would probably be fair to say that it has never recovered.
‘Battered baby syndrome’ had first been described in the nineteenth century but its study had recently been taken up again by Kempe et al. (1962) and its paediatric implications had been described nine years later (Kempe, 1971). So it would be unrealistic to expect the professionals concerned to have had the awareness and understanding of child abuse that is now taken for granted. The Maria Colwell case brought the issue to prominence in the UK.
The Committee were unable to agree a unanimous report, with Olive Stevenson offering a different account of the events that led up to the revocation of the Fit Person (by then Care) Order in respect of Maria on 17 November 1971 but she did not dissent from the rest of the report or its conclusions.
- The Committee were unable to agree a unanimous report.
- Maria had been born on 25 March 1965 and died on 6/7 January 1973 at the hands of her step-father.
- When she was four months old, her mother had given Maria to her sister-in-law and, apart from a brief period when she was returned to her mother and then placed with another woman, she had lived with her aunt until she was six and a half years old, most of that time under the care of East Sussex County Council.
- No love was lost between Mrs Colwell and her sister-in-law.
- When Mrs Colwell began proceedings to have Maria returned to her, East Sussex County Council did not oppose the application in November 1971 and were asked by Brighton Council to carry out the supervision of Maria ordered by the court.
- From April to October 1971 visits by Maria to her mother and future step-father had been gradually increased but, in spite of Maria’s increasing distress at these visits, she had been placed home on trial in October.
- Events in April 1972 involving the family, their neighbours, the police, the NSPCC and Brighton Housing Department do not appear to have been taken sufficiently seriously.
- Neighbours made frequent reports of abuse/neglect of the children to the NSPCC and the Housing Department.
- From 1 June to 1 December 1972 Maria was not seen by the social worker who was under the impression that the NSPCC were visiting.
- Prior to her move from infants to junior school, an education welfare officer had become involved but she did not know about the supervision order.
- After the move to junior school Maria’s attendance began to fall off, her last attendance being 20 November.
- An incident involving the family, neighbours and the police in November did not appear to have been taken seriously enough.
- A flurry of visits by professionals in December 1972 was unable to prevent the death of Maria at the hands of her step-father on 6 January 1973.
- Communication and co-ordination within and between the agencies involved had been unsatisfactory.
- Because the social worker’s report to court took the line taken by her employer, it might be useful to have had a report from an independent social worker.
- A supervision order lacks the powers to compel medical examinations and does not require regular visits.
- East Sussex County Council was primarily responsible for the failures which led to Maria’s death but Brighton Council and the NSPCC had also failed her in various ways and the police should have passed on the little information they had.
In Chapter 1 Introduction, the Committee set out how they were appointed by Sir Keith Joseph, Secretary of State for Social Services, on the 17 July 1973. Maria Colwell had died in January 1973 of multiple injuries inflicted by her step-father, William Kepple, who was found guilty of murder on 16 April 1973. However, on 19 July 1973 the Court of Appeal had substituted manslaughter and sentenced him to eight years imprisonment.
The Committee had held a preliminary hearing on 24 August 1973 followed by 41 days of public hearings between 9 October and 7 December 1973 when they had heard seventy witnesses, received thirteen written submissions and examined 99 documents and exhibits. They had also visited the estate where Maria had lived and the schools she had attended
The Committee regretted that they had been unable to agree on the report.
In Chapter 2 Narrative, from the first part of which Olive Stevenson dissented, they say that Maria had been born on 25 March 1965 and died on the 6/7 January 1973. There had been a feud between the parents’ families; their mother had often left the children alone and they were neglected and dirty; their mother had been warned by the NSPCC and the Children’s Department
In August 1965, when Maria was four months old, her mother had given her to her sister-in-law, Mrs Cooper. Subsequently, the family situation had deteriorated and, following a case conference on 3 December, East Sussex County Council had obtained a Place of Safety Order on the other four children, removed them from the home and obtained Fit Person Orders in respect of them. Two children had been boarded out with their maternal grandmother and two with foster-parents.
On 4 June 1966 Mrs Colwell had removed Maria from Mrs Cooper because she intended to set up with William Kepple but a week later the family was homeless and she placed Maria with another woman, prompting the NSPCC to seek a Place of Safety Order. Maria was returned to Mrs Cooper under an Interim Order and, with the granting of a Fit Person Order, it was up to East Sussex County Council to decide whether to board her with Mrs Cooper. They did not regard this as an ‘ideal’ foster-placement because Mrs Cooper was reluctant to go along with the long-term plan of returning Maria to her natural mother. The Committee noted, however, the generally favourable comments they had received from those who knew Mrs Cooper.
In July 1967 Mrs Colwell vetoed plans by Mrs Cooper to have Maria christened because she had agreed to become Roman Catholic when she married Mr Kepple; Mrs Colwell had children by him in November 1967, December 1968 and November 1969.
In October 1968 Mrs Cooper moved to Brighton but Brighton Council were unaware of her status until June 1971.
Over the next few years there was no general improvement in Mrs Colwell’s family situation; there are complaints in 1969 and 1970 about Mr Kepple and Mrs Colwell leaving the children. But on 20 August 1969 Mrs Colwell applied to Hove Juvenile Court for a variation in the Order relating to Maria which was refused on the grounds that they had no jurisdiction.
In April 1970 Maria started at infant school and Diana Lees took over as the family’s social worker; she was newly qualified and by 1972 was carrying an average caseload of 60-70 cases. She gradually got round all the family but only met Mr Kepple in November when he said Mrs Colwell wanted Maria back. During her visit Maria had been upset by the suggestion that she should return to her natural mother and in October 1970 Maria was distressed by a visit to her mother’s new council flat. Diana Lees noted that, during her visit on 5 February 1971, Mr Kepple had expressed indifference as to whether Maria came home.
At a case conference on 26 April an eventual return home for Maria was envisaged, even though the ideal of a gradual transition from the Coopers to Mr Kepple and Mrs Colwell would not be possible because of the animosity between Mr Kepple and Mrs Colwell and the Coopers. The plan therefore was to enable Maria to get to know her mother and Mr Kepple more until it was possible to make a sudden transfer.
The two Committee members responsible for this part of the report noted that none of the witnesses had supported the assumption that it would have been easier to return Maria to her natural mother when she was younger. They also pointed out that, in relation to the argument that the social workers had acted according to best practice at the time, it might not be reasonable to criticise the social workers as in any case there was insufficient evidence to do so, but it was not unreasonable to criticise the standards of practice at the time.
Following the case conference there had been a series of home visits over the summer of 1971 with Diana Lees noting the ‘negatives’ for Maria. When she stayed for a week in August 1971, Maria had been fearful of not being able to return to Mrs Cooper. By September Maria was resisting visits and some were cancelled; the school was also expressing concern over the visiting arrangements and Maria had absconded from school to avoid one visit, being found hiding at Mrs Cooper’s.
On 6 October 1971 Mrs Colwell applied for revocation of the Care Order and Diana Lees made preparations for Maria to return home on trial in October and to transfer to a new infants school on 1 November 1971. The two Committee members could not see why Diana Lees took this decision without consulting a psychiatrist or paediatrician; after all, what happened had been anticipated in April 1971.
When Maria went home on trial to Mrs Colwell’s on 22 October 1971 she ran away because she was not allowed to ‘go home.’ In her report to Hove Juvenile Court on 17 November 1971 Diana Lees referred to Maria’s ‘confusion over where her loyalties lie’ (Committee of Inquiry into the Care and in Relation to Maria Colwell, 1974, §67, p. 29); however, in the two Committee members’ view, there was actually no confusion and they argue that social workers were not qualified to make judgements about Maria’s trauma. They note that the Coopers had not been told about the hearing.
Olive Stevenson’s dissent ended here.
The court made a Supervision Order to Brighton but East Sussex agreed to carry on the supervision; among the weaknesses in this arrangement was that Diana Lees would not know the other local authority staff who interacted with the family.
In April 1972 a neighbour complained to the NSPCC about Mr Kepple’s treatment of Maria and an NSPCC officer and a detective constable visited various neighbours but Maria had been primed what to say about the injuries and the Committee argue that the NSPCC should have made further investigations rather than leaving it for the neighbours to report anything else.
On 16 April 1972 there was an argument between Mr Kepple and Mrs Colwell about whether Maria could go out with a neighbour in the car in the course of which it was revealed who had called the NSPCC. This resulted in a fight with the neighbour to which the police were called but they did not see fit to alert the NSPCC or the Social Services Department. The following day a neighbour reported the ill-treatment of Maria and also the previous day’s events to the Social Services Department but there was no contact with the police about these events. The same day Diana Lees and the NSPCC officer visited the neighbours’ houses and the next day Diana Lees visited Maria but her record of the injury is not the same as the NSPCC’s; she advised Mrs Colwell to take her to the doctor but she did not ensure that this happened. In fact, Maria was not registered with a doctor and when she was registered on 21 April 1972 there is no record of an examination.
On 24 April 1972 a neighbour complained to Brighton Housing Department about the family and their ill-treatment of Maria but the significance of these events was not grasped. Her teacher did not accept Maria’s explanation of her injuries but this did not reach the Social Services Department or the NSPCC. The Committee note that a change in the date of school medical examinations had meant that Maria had missed her medical examination though the change of school.
On 13 May 1972 Mr Kepple and Mrs Colwell get married.
On 1 June 1972 Diana Lees visited the Kepples; on her next visit she did not see Maria and the next time she saw her was 1 December 1972. She did not complete a six-monthly report for Brighton Council.
On 18 July Maria was sent home with suspected impetigo and did not attend school again until her move to the juniors in September. The infant school referred her to the education welfare officer who visited and contacted the health visitor who visited but did not see Maria; neither the education welfare officer nor the health visitor knew that Maria was under supervision. In fact, there was nothing in the infant school records about Maria being under supervision though the staff knew; so the junior school staff were unaware of this and did not send essential information to Diana Lees.
In August a neighbour telephoned the NSPCC to report bruises but this message was not passed on to the NSPCC officer. In fact, Diana Lees thought the NSPCC officer was visiting but she only visited on 18 August 1972 (when she saw Maria) and 27 September 1972 (when she did not). According to the NSPCC, a verbal report of this visit was made to Diana Lees on 10 October 1972 – except that Diana Lees was on leave that day.
In August a neighbour discovered Maria barred in her own room at home.
On 5 November the police were called to an incident involving Mr and Mrs Kepple and on 7 November neighbours complained to the Housing Department about the family and their care of the children. The following day, a member of the Housing Department staff visited the neighbours and Mr Kepple and submitted a report; however, this was not passed on to the Social Services Department by his senior until 22 November 1972 even though the report had mentioned the police visit on 5 November; none of this was passed on to Diana Lees.
Maria was becoming more withdrawn at school, her last attendance being on
20 November; staff were told she was ill but her oldest sister, who babysat, reported no illness. When Diana Lees visited the maternal grandmother, who was caring for two of the children, on 9 November, she expressed concern over Maria but Mr Kepple put off the first appointment on 20 November and Diana Lees eventually visited on 1 December. On 27 November, there had been an anonymous call to the NSPCC saying that Maria was bruised but the NSPCC failed to pass on this message.
When she visited, Diana Lees advised Mrs Kepple to seek medical help; on the same day the school raised its concerns with Brighton Social Services Department who said that physical injuries were an NSPCC responsibility.
On 4 December 1972 the education welfare officer discovered that Maria was on a supervision order; she visited and made an appointment for the school clinic but Maria did not attend. Maria was eventually seen by a doctor on 6 December 1972 but he found nothing that could be associated with a specific form of violence; the committee noted that the doctor had no history to go on.
The education welfare officer raised the possibility of proceedings with East Sussex County Council but Diana Lees was not told of this; a neighbour phoned Diana Lees and left her sister’s telephone number; Diana Lees later said she tried to phone back but received no reply. The neighbour’s sister says there was no call; there was no follow up anyway.
On 13 December the education welfare officer and Diana Lees both visited but Maria did not attend the follow up visit with the doctor.
On 18 December there was an anonymous complaint to the NSPCC which was passed on to Diana Lees who said there was no need to visit because she had seen Maria the previous week.
On 27 December 1972 the last visit by her oldest sister took place.
On 6 January 1973 Maria died of serious bruising and internal injuries; her stomach was empty.
In Chapter 3 Comments, the Committee set out the issues they identified:
- Recording: case notes and messages
Though overall standards of recording were high in East Sussex County Council, the Boarding Out Regulations set out clear expectations, and records needed to separate fact and impression, record sources and record the detail of the explanations someone gave; there had been failures in transmitting information to others.
ñ Communication within and between schools
The school record cards held inadequate information and were not seen as important by teachers, while the medical cards mostly recorded medical material; the slips passed between teachers and education welfare officers were inadequate as records; greater importance needed to be attached to informal communication and the role of the school secretary.
ñ Communication between schools and social services departments
The Committee had found conflicts of evidence between the schools and the social services departments, partly because there was little recording by teachers and it was variable by social workers; Diana Lees had not known that the infant and junior schools were different schools and the education welfare officer had not known of Diana Lees’s involvement until November 1972.
- Social services departments and the NSPCC
People naturally turned to the NSPCC and there were normally good relationships between social services departments and the NSPCC but this could mean there was no formalisation of their respective responsibilities.
- Social services departments and housing departments
Clear visiting arrangements and relationships were needed.
- Social services departments and the police
Police procedures were inadequate in cases involving children but there were no problems about referring children to social services departments.
- Social workers and the local community
Trust needed to be developed.
- Communicating with children
Social workers need to see the child alone and be aware of the child’s communication with others, for example, teachers, to supplement the direct communication with the child.
- Prospective step-parents
Social workers should check with the police, the doctor and social security; they might have to ask for permission in the light of the step-father’s right to confidentiality and they should not regard a refusal of permission as relevant to child’s welfare but they should at least make the effort.
- Independent social worker’s report
At the juvenile court hearing the case went through by default because East Sussex County Council had decided not to oppose the application and the social worker’s report followed that line; this suggests the need for an independent report.
The Coopers had no right to attend but it might have been useful if they could have; one possibility might have been a wardship application so that the High Court could make the decision.
- Supervision Orders
With no regulations governing Supervision Orders the social worker lacked powers to act; there was no requirement for a medical examination or for statutory visits.
In Chapter 4 Conclusions, the Committee conclude that East Sussex County Council had been primarily responsible because they:
- had not opposed the revocation,
- had not attempted to gain time for Maria,
- had failed to monitor the return,
- had failed to react in April 1972,
- had failed to provide adequate supervision from 1 June to 1 December 1972.
Brighton Council had:
- failed to pass on information, both to East Sussex County Council and between the housing and social services departments,
- failed to press for the six-monthly report.
The NSPCC had:
- flawed messaging and communication systems,
- misread the April 1972 incident,
- failed to follow its own procedures.
The police had little involvement but had failed to pass on information.
In Chapter 5 Narrative and comment on the period from Maria’s birth in March 1965 up to the revocation of the Fit Person Order by the Hove Juvenile Court on 17 November 1971, Olive Stevenson examines the impact of the separation on Maria and the family interventions, noting that Mrs Colwell had always retained an interest in Maria and resented the placement with Mrs Cooper who always upset Mrs Colwell. She also looks at the role of the wider family and the social worker’s perceptions of the feelings of all parties and undertakes a detailed analysis of the records.
She examines the legal framework within which the social workers were operating and their confusion over the concept of a ‘blood tie’ and stresses that it was not a black and white situation and that there was no clarity about Maria’s ‘true feelings.’ She concludes that the failure to seek a psychiatric opinion was not significant and says there is no value in a hierarchy of blame.
There is nothing groundbreaking in this report; as Tom O’Neill (1981) observes, the similarities between Maria’s case and his brother’s are striking. The professional training which social workers had received in the previous two decades had not addressed the communication failures which had underpinned both cases. The need to see children alone and, if necessary, examine them had been stressed as long ago as 1894 by a Departmental Committee of the Poor Law Board (Heywood, 1978) and was to be echoed a decade later by the Hughes Committee (Committee of Inquiry into Children’s Homes and Hostels, 1986).
The decision to return Maria to her mother was almost certainly influenced by Bowlby (1952); though much of the research included in Clarke and Clarke (1976) had been published, it would not have been part of the staple of a social worker’s training. Maria had a secure attachment with her aunt, having been placed with her when she was four months old, and the decision to break this attachment would have been damaging even if Maria had not died because, for her, the person in whom she had invested had been unable to protect her. As Wiener and Wiener (1990) were to find two decades later, social workers seem to be particularly powerless when faced with a determined parent and the outcome is almost always harmful for the child.
There is little doubt that both the decision to return Maria to her mother and future step-father and the planned mode of execution were flawed and the same failure to recognise children’s distress that was apparent in the Pindown records (Levy and Kahan, 1991) was present in the social workers’ records in this case. Yet such failures appear to characterise situations where people’s attention is on something else; thus it was the entry of Christina Maslach into the Stanford Prison Experiment that led to its premature termination. The researchers could not see the damage they were doing because they were so caught up in the experiment (Zimbardo et al., 2000).
The sequence of incidents and complaints which marked Maria’s last year was to be paralleled a decade later in the career of Frank Beck when complaints made against him were not followed up (Kirkwood, 1993).
The Committee were probably optimistic in expecting that granting new powers to social workers in relation to supervision would have helped. The story of Maria’s last months is a combination of professional and administrative failures, including the simple failures to seek outside opinion and to recognise Maria’s distress even while recording it, failures also shared with the Staffordshire social workers (Levy and Kahan, 1991), and to see Maria and to have her examined, something which, on the evidence of the Baby P case, some social workers have still not grasped.
Bowlby, E. J. M. (1952). Maternal care and mental health: a report prepared on behalf of the World Health Organization as a contribution to the United Nations programme for the welfare of homeless children (Second ed.). Monograph Series No 2. Geneva: World Health Organization. Previously published in the Bulletin of the World Health Organization 1950.
Clarke, A M and Clarke, A D B (Eds.) (1976) Early experience: myth and evidence London: Open Books See also Children Webmag May 2010.
Committee of Inquiry into Children’s Homes and Hostels (1986) Report of the Committee of Inquiry into Children’s Homes and Hostels (Chairman: His Honour Judge William H Hughes) Belfast: Her Majesty’s Stationery Office
Committee of Inquiry into the Care and Supervision Provided in Relation to Maria Colwell (1974). Report of the Committee of Inquiry into the care and supervision provided by local authorities and other agencies in relation to Maria Colwell and the co-ordination between them (Chairman: T. G. Field-Fisher) London: Her Majesty’s Stationery Office
Heywood, J S (1978) Children in care: the development of the service for the deprived child (Third ed.) London: Routledge & Kegan Paul
O’Neill, T (1981) A place called Hope: caring for children in distress Oxford: Blackwell See also Children Webmag May 2009.
Wiener, A and Wiener, E (1990) Expanding the options in child placement Lanham MD: University Press of America See also Children Webmag January 2010.
Zimbardo, P G, Maslach, C and C. Haney, C (2000) Reﬂections on the Stanford Prison Experiment: genesis, transformations, consequences In T Blass (Ed.) Obedience to authority: current perspectives on the Milgram paradigm Chapter 11 London: Lawrence Erlbaum