The Jasmine Beckford Affair
| Author | Robert Dingwall |
| DOI | http://doi.org/10.1111/j.1468-2230.1986.tb01700.x |
| Published date | 01 July 1986 |
| Date | 01 July 1986 |
REPORTS
OF
COMMITTEES
THE
JASMINE
BECKFORD AFFAIR
ONE
of the conventional responses of the British state to the
revelation of a major disaster, accident or scandal is to set up an
inquiry under the leadership of a lawyer.
A
Child
in
Trust,
the
Report
of
the Panel
of
Inquiry into the Circumstances surrounding
the Death of Jasmine Beckford, under the chairmanship of Louis
Blom-Cooper, Q.C., is a recent and well-publicised example.’ It is,
however, submitted that a review of this report will underline the
intrinsic limitations of such an approach either as a basis for reform
or as a means of accountability.
Blom-Cooper’s report stands in an honourable tradition of
investigations into apparent failures in the state’s care and protection
of children. The historic inquiry by Sir Walter Monckton, K.C;,
into the death of Denis O’Neill in
1945
contributed significantly to
the demand for reform which resulted in the Children Act
1948.’
More recently, the report in
1974
on the death of Maria Colwell,
from a panel led by
T.
G.
Field-Fisher, Q.C., played a part in
launching the present, continuing wave of concern about child
care.3 Between
1973
and
1981,
a D.H.S.S. review identified
18
other inquiries,
of
which
12
appear to have been chaired by
1awye1-s.~
One
of
the striking features of these inquiries is the repetitive
character of their findings and recommendations. Indeed the
D.H.S.S. review was conducted in response to a widespread
perception that the various reports had a great deal in common.
But this very recurrence suggests that these inquiries are actually
failing to make any lasting impact on the everyday practice of the
occupations and organisations under scrutiny. It will be argued that
this results from fundamental limitations in the legal approach to
the problems involved. A discussion of these may have a general
significance for lawyers who become involved in other investigations
of
untoward events, as well as contributing to a specific assessment
of
the value of these quasi-judicial inquiries into child
death^.^
~ ~ ~~
A
Child in Trust
(1985).
N.
Parton,
The Politics
of
Child
Abuse
(1985).
Department
of
Health and Social Security,
Child
Abuse:
A
Study
of
Inquiry
Reports
1973-1981
(1982). The Chairman’s qualifications are not always given but it is likely that
most
of
those described as former clerks
to
local authorities would have been lawyers.
Since 1981, published reports have included those into the deaths
of
Richard Fraser
(1982), chaired by a retired local government lawyer, and Lucy Gates (1982), chaired by
a Q.C. At the time
of
writing (early 1986), a further inquiry, into the death
of
Tyra
Henry, is in process under yet another Q.C.
The term “untoward events” will be used as a general and neutral description
for
scandals, accidents, disasters and other unexpected and catastrophic failures
of
social
or
natural organisation.
489
*
J.
Heywood,
Children in
Cure
(1978).
490
THE MODERN LAW REVIEW
[Vol.
49
Maria Colwell:
Accounting
for Disaster
Two contrasting approaches to the problem
of
explaining untoward
events are illustrated by the majority and minority reports of the
inquiry into the death
of
Maria Colwell.6 The majority report, by
Field-Fisher and Alderman
Mrs.
M.
R.
Davey, established the
pattern for most of the subsequent inquiries. It explains Maria’s
death
in
terms
of
errors or mistakes which vitiated the functioning
of
the child protection system in East Sussex. The authors do
attempt to deal with this in terms which recognise the contribution
of organisational as much as individual failure:
“.
. .
we think it quite impossible, and indeed unfair, to lay
the direct blame for
.
.
.
inade uacies in the care and
supervision of Maria upon any in&vidual
.
.
.
Many
of
the
mistakes made by individuals were either the result
of,
or were
contributed to, by inefficient systems.”’
Despite such concessions to organisational explanations, the main
thrust of the majority analysis is on the identification of individual
errors. Having taken parental responsibility, the state must ensure
that “the system works as efficiently as possible at every level
so
that individual mistakes which must be accepted as inevitable, do
not result in disaster.”8 Blame is only shared with the system to the
extent that it fails to provide means
of
limiting the effects
of
its
employees’ mistakes.
Olive Stevenson’s minority report adopts a rather different
approach. Although she agrees with the majority in identifying a
number of specific failures, she seeks to establish that the social
workers involved in Maria’s case did not consistently make mistakes
but, at times, reached unfortunate decisions for good professional
reasons. Any social worker in the same situation could legitimately
have made similar use
of
the then-current psychological knowledge
about parentkhild relationships, recognised the same limitations of
care resources and acknowledged the public ambivalence between
the rights
of
parents and intervention to protect children. Maria’s
care did not routinely fall short
of
accepted professional
standard^.^
The majority report of the Colwell inquiry has considerable
similarities to the accounts
of
major accidents and natural disasters
analysed by Turner.” It treats the untoward event (Maria’s death)
Department
of
Health and Social Security, Report
of
the Committee
of
Inquiry into
’
Ibid. at para. 241.
Ibid. at para. 242.
Compare this with the Bolam principle, “that a doctor is not negligent if he acts in
accordance with a practice accepted at the time as proper by a responsible body
of
medical opinion even though other doctors adopt a different practice.” Sidaway
v.
Bethlem Royal Hospital Governors and Others
[1985]
1
All
E.R.
643, 649
per Lord
Scarman discussing Bolam v. Friern Hospital Management Committee
[1957]
2
All
E.R.
118.
lo
B.
A.
Turner, Man-Made Disasters
(1978).
This
study is based
on
a sample
of
84
from
449
accident and disaster reports published by the British government between
1965
and
1975.
the Care and Supervision Provided
in
Relation to Maria Colwell
(1974).
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