'This is a reproach to everyone with responsibility for child safety'
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Lord Laming describes the 108 recommendations that accompany his report into the death of Victoria Climbié as an "agenda for action now".
Although the proposals amount to a blueprint for a complete restructuring of the provision of social care for children and families, Lord Laming claimed ministers could implement the bulk of them within six months.
"The best that we can hope for from the terrible ordeal suffered by Victoria, who was brought to this country for a better life, is that this report is the last of its kind," he said.
General recommendations (1-16)
The report's most radical suggestion is for the formation of a new Children and Families Board, chaired by a minister of cabinet rank and including ministerial representation from all government departments with responsibilities for the welfare of families and children. The board would oversee a new National Agency for Children and Families, which would be led by a chief executive with the functions of a Children's Commissioner for England. Children's charities have been campaigning for such a commissioner for several years.
Lord Laming rejected the idea of a National Child Protection Agency, saying the needs of a child and his or her family "are often inseparable".
The new national agency would oversee the implementation of legislation and policy at a local level and would be able to conduct reviews of serious cases.
At a lower level, every local authority would be required to set up a committee of members for children and families. Lord Laming said such a national structure would create " a clear and unambiguous line of managerial accountability within and across public services".
Children's database (17)
The inquiry called for all children to be placed on a national database until they became 16, for their own protection. Lord Laming said he was concerned at poor record-keeping and exchange of information between services.
He said people who deliberately harmed children often covered their tracks. "The benefit of such a database would be that every new contact with a child by a member of staff from any of the key services would initiate an entry that would build a picture of the child's health, developmental and educational needs."
Social care (18-63)
The inquiry exposes the lack of support given to vulnerable children out of office hours when "a single member of staff ... is frequently expected to cover all social care needs within an authority". It calls for funding for local authorities to provide 24-hour specialist services for children and families "as do the other 'emergency' services, such as the police and health service".
All local authorities should set up 24-hour phone lines for members of the public who wish to report concerns about children, the report says.
Lord Laming also calls for children to be spoken to within 24 hours of allegations that they are at risk, and for children to be spoken to alone and accommodation to be visited.
Every child assessed as "needing a service" should be allocated a social worker. In cases where this is not possible, contact with the child must be maintained.
Many recommendations concern the need for good record-keeping and communication between all the different agencies.
Lord Laming said: "Some of the recommendations are disarmingly self-evident and, for the most part, should be current good practice. That they have had to be made should be a reproach to everyone with responsibility for the safety of children."
He said all chief executives of local authorities should conduct "a thorough audit of the quality and effectiveness of services to children and families".
Health care (64-90)
Doctors who suspect a child is being harmed should be prepared to take a history directly from a child even if the carer has not given consent.
And hospital chief executives must ensure that no child subject to child protection concerns is discharged from hospital without the consent of a consultant or senior paediatrician. Doctors or nurses who suspect a child has been harmed must inquire about previous admissions to hospital. The report states: "The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease."
All doctors specialising in child protection and all consultant paediatricians should be revalidated in the diagnosis and treatment of deliberate harm, the report says.
The Royal College of General Practitioners should explore the possibility of doctors taking note of children's living conditions and school attendance record in making an assessment of the child's welfare.
GPs should be trained to recognise symptoms of deliberate harm to children.
Police (91-108)
Lord Laming is deeply critical of the role of police child protection teams in the case of Victoria Climbié. London officers complained to the inquiry that they were having to cope with high numbers of murders, and that child protection was not a priority issue. One officer told the panel that "child protection and ordinary policing are two different things".
Describing such an approach as "fundamentally flawed", Lord Laming said: "I believe that they are not different things."
As one of its recommendations, the Climbié report said: "Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime."
He said that when social services received reports that suggested criminal activity against a child then they should "inform the police at the earliest opportunity".
The Climbié inquiry heard evidence that many child protection officers lacked experience in investigative work.
The report said police forces should staff such teams with officers who were "well trained in criminal investigation" and that chief constables must ensure that fully trained detectives were attached to these units to work on the most serious cases.