It was a case that sickened a nation.
Victoria Climbié came to Britain from Ivory Coast four years ago, a sunny 8-year-old traveling expectantly with her aunt, hoping for a brighter future and a better education.
Eleven months later, the young girl was dead - the result of systematic beating and torture by her aunt that one pathologist and at least one doctor said was the worst case of child abuse they had ever seen.
If the case was horrific enough, the real tragedy was that it happened under the noses of dozens of professionals who failed to prevent it. Poor coordination, negligent care, and a lack of overall responsibility ensured that she fell through the cracks of the British social-welfare system.
Now the government has signaled that enough is enough. Last week, it unveiled a sweeping reform package it hopes will ensure that vulnerable children never again slip through the net in the way Victoria did.
The plan is to issue a new credit card-style identity number to all children to make it easier to keep tabs on their health and welfare. The measures also call for a new Children's Commissioner to act as a voice for youngsters on the national stage; and a revamp of the grass-roots health-and-welfare record to streamline a muddled, tired bureaucracy.
"Victoria Climbié was the straw that broke the camel's back," says Chris Hanvey, the director of operations in Britain for Barnardo's, a children's charity. "The feeling from government was that they had a system to protect the needs of children that simply wasn't working."
In fact, many say, the system has long been failing. Victoria's was just the latest in a litany of grim cases that have punctured the nation's consciousness over the years.
Since the 1970s, when the British social-welfare bureaucracy was last overhauled, there have been more than 50 inquiries into fatal instances of child abuse. And over the past 30 years, at least one child has died every week in Britain as a result of an adult's cruelty. Last year, 76 minors were homicide victims.
More than 30,000 children in Britain are on an at-risk register. And babies are five times as likely to be killed as any other age group, according to the National Society for the Prevention of Cruelty to Children, which calls the British trend a "national outrage."
International comparisons bear this out. Although the World Health Organization says that infants in developing nations are at far greater risk of child abuse, many richer European nations have a better record than that of Britain. Sweden, for example, suffered only four cases of infanticide in the 15 years to 1996, charity workers say, while in the same period, the British total ran well into the hundreds.
"We do have a bad record on child abuse in this country, though the things that happened to Victoria Climbié are extremely rare," says Christian Janner, a spokeswoman for the National Families and Parenting Institute, an independent charity. "The government is now trying to create a climate of people who will speak up for children, who will be directly responsible for them, somewhere where the buck will stop," she adds. "It's to establish a chain of command so that people know who is ultimately responsible."
This chain was noticeably lacking in the Climbié affair. The girl came into contact with no fewer than 12 official agencies - hospitals, child-protection teams, social-services departments - during her short, brutal stay in Britain.
Despite repeat visits to the hospital for bruising and other signs of assault, and a probe into her home life, nothing was done. An inquiry after her death blamed "organizational malaise," indolence, and chronic "buck passing" for the fact that no one group took responsibility for her case.
That will all change under the government revamp, which plans to set up Children's Trusts at the local level to bring experts - psychologists, social workers, education officials - together, with a local director ultimately accountable.
The idea is that in a case like Victoria's, the various officials would have been able to compare notes and realize instantly that something was seriously wrong.
But the outlined reforms have also drawn criticism. Victoria Climbié's parents said they did not meet all of the recommendations produced by the inquiry into their daughter's death.
In particular, there is concern that simply changing one bureaucratic setup for another may not eradicate a culture of underfunding, disenchantment, and even negligence among some social workers.
"Structures will never save children's lives," says Dr. Hanvey. "The acid test is would a Children's Commissioner have prevented Victoria Climbié's death? The answer has to be no. It all came down to people not fulfilling the functions they should have done."
One child psychologist who has worked in the state sector for 10 years went even further, saying that until hospitals and social services are better funded there will never be enough resources to ensure that every vulnerable child is being monitored.
"If you feel there is risk to child, you have a responsibility to hand over [information] to social services, but the problem is that they don't always perceive the risk that you perceive," said the psychologist, who did not want to be named. "Their case load is very high and they just don't have the resources to see hundreds of children."
She said the idea of Children's Trusts made sense: Parents of troubled children will no longer have to connect with professionals in different locales, but will be able to get the help there is from one group. .
But money is a crucial factor. The government has been spending generously on health in general to upgrade the decrepit National Health Service, but it remains unclear how much funding will be available to support the new plans for child welfare.
"The concept of Children's Trusts is a good one because it will force us to work more effectively as teams," says the psychologist, "but only if they can direct more funds into the system."