The Bright Yellow Form: Safeguarding in the UK

A Journey That Should Have Saved Her

She died at eight years old. On the medical chart, her name was listed as Anna Kouao. It wasn’t until days later, once the inquiry began, that investigators discovered her passport. The photo showed a child who clearly did not match the patient. Her true identity was soon uncovered: Victoria Adjo Climbié.

Victoria was the fifth of seven children, born on 2 November 1991 in the Ivory Coast to Francis Climbié and Berthe Amoissi. In 1998, her great-aunt, Marie-Thérèse Kouao, a French citizen, visited the family and offered to take Victoria to Europe for a better education—a practice not uncommon in West Africa. Trusting Kouao’s intentions, her parents were thrilled at the opportunity for their bubbly, smiling daughter.

But after arriving in Paris, Marie-Thérèse began physically abusing Victoria. Staff at the primary school she attended quickly noticed her deteriorating appearance and increasing injuries. Authorities were alerted and had begun investigating, prompting Kouao to flee with Victoria to London.

In London: A Descent into Darkness

In April 1999, shortly after their arrival, Kouao met Carl Manning, a London bus driver. She and Victoria moved into Manning’s one-bedroom flat in Tottenham, North London—where Victoria now had not one, but two abusers.

One night in July, Kouao dropped Victoria off with her after-school childminder, Priscilla Cameron, saying she could no longer care for the child. It was late, so Cameron allowed Victoria to stay the night. When they asked her to undress, they discovered a black eye and cuts on her scalp. Alarmed, they rushed her to Central Middlesex Hospital’s A&E. Once in a medical gown, doctors discovered cigarette burns up and down her legs. A registrar admitted her for non-accidental injuries.

However, once on the paediatric ward, the consultant overruled the registrar, diagnosing scabies instead. He dismissed the injuries and discharged Victoria back into Kouao’s care.

Only weeks later, Victoria was taken to North Middlesex Hospital with scald injuries to her head and face. Kouao claimed she had poured hot water on her to stop her from scratching. Staff were suspicious. They described Victoria as a “ray of sunshine” on the ward—but noted how she became withdrawn and quiet whenever Kouao visited. Despite severe burns causing her scalp to peel, photos show Victoria still smiling. Nurses referred the case to child protection services. But after a brief investigation, Kouao’s explanation was accepted. Victoria was discharged on 6 August 1999, with no protective measures in place.

After that, Victoria was rarely seen in public.

In February 2000, she was brought once more to North Middlesex Hospital—this time unresponsive. Her core body temperature was so low it couldn’t be read on standard equipment. A post-mortem revealed 128 separate injuries. The pathologist stated: “No part of her body was spared.”

In her final six months, Victoria suffered horrific abuse and neglect.Kouao and Manning beat her with bicycle chains and hammers, burned her with cigarettes, and forced her to sleep in a bin liner in an unheated bathroom. They were convicted of murder and sentenced to life imprisonment on 12 January 2001.

A System That Failed Her

What made Victoria’s case especially disturbing was not just the cruelty she endured, but how many professionals she encountered—and how each failed her. Victoria’s death exposed how every professional failed her. Between April 1999 and February 2000:

3 social services referrals

5 hospital visits (two involving A&E)

2 police encounters

Her death triggered a landmark public inquiry, led by Lord Laming, which revealed systemic failings: poor inter-agency communication, failure to escalate obvious signs of abuse, a lack of professional curiosity, and an overreliance on the caregiver’s narrative.

Lord Laming concluded: “Her death was not due to a lack of resources, but a gross failure of the system to act on clear signs of abuse.” His inquiry led to major reforms in UK child welfare, including the Children Act 2004 and the Every Child Matters framework.

My First Encounter with Safeguarding

It was during a quiet night shift in the paediatric ED that I first came across her story. I went down a rabbit hole into the UK’s safeguarding history—a concept that was new to my nursing practice.

In the UK, each major shift in safeguarding legislation has followed a tragedy. Long before Victoria, there was Maria Colwell. Her death in 1973 sparked the Butler Report and the first real reckoning with child protection in the UK. It laid the groundwork for the system I would come to rely on decades later, standing in a paediatric A&E ward, wondering what form to fill out next.

Over the next two decades, significant laws followed. The Children Act 1989 was transformative. It established that the child’s welfare is paramount and required local authorities to investigate suspected abuse. It marked a shift towards proactive, multi-agency child protection.

But even with all these measures, they did not save Victoria. The Laming Inquiry of 2003 led to a complete overhaul of the child protection system, culminating in the Children Act 2004 and the introduction of Local Safeguarding Children Boards (LSCBs), embedding inter-agency cooperation into law. This ensured that social services, health, education, and police worked collaboratively. It also launched the Every Child Matters framework, which wasn’t just policy—it was something I saw in action each time a child’s mental health crisis triggered a team response, ensuring they weren’t just treated, but supported. It reinforced that every child has the right to be healthy, safe, to make a positive contribution, and to attain economic well-being.

From Policy to Practice: The Yellow Form

These principles became part of my everyday work in A&E. Whenever a child arrived with any of twenty-four specific concerns—from substance use to sexual assault to a bruise on a non-mobile baby—I completed a bright yellow safeguarding form. Some triggers stood out immediately, but others—like burns in children under three or delayed presentation of illness—often went unnoticed in the U.S. system. That form acted as a safety net.

Depending on the case, it was handled either internally by the safeguarding team or externally referred to Children’s Social Care. Some cases triggered an inter-agency referral to the Multi-Agency Safeguarding Hub (MASH)—a centralised unit involving social services, police, and healthcare. These agencies are legally obligated to follow up on concerns.

The bright yellow form also captured who else lived in the home and which school the child attended—casting a wide net to identify vulnerabilities before tragedy could occur.

By the time I arrived in England, safeguarding was well established. The cases of Maria, Victoria, and others were not in vain—they shaped the system I came to Trust.

Learning About Safeguarding

I thought I understood child protection—until I sat through a four-hour induction course at HHFT, opening a door to a world of protections I hadn’t known existed. It covered six core principles: empowerment, prevention, protection, proportionality, accountability, and partnership. It also included the 2015 “Prevent” duty under the Counter-Terrorism and Security Act, and sections on online bullying and grooming—recognising modern threats to children.

My education was supplemented by a tall Welsh caseworker, always in heels—you’d hear her shoes before you saw her. She was one of the leads for the Safeguarding Children’s Team (SCT). Though busy, she took time to educate new overseas nurses on the team’s mission. She stressed that the yellow form wasn’t punitive—it was there to help. That mindset shaped how I viewed safeguarding.

Throughout my time in England, I used that form many times—from patients arriving following deliberate self-harm to a young girl brought in by ambulance after being found intoxicated in the park. Or the teenager who got into a fight at school and arrived with a fractured hand. I remember once completing the form for a three-year-old whose overwhelmed mother kept shouting at him. The child repeatedly said, “I am a very bad boy.” Those were likely the words he heard most. The mum needed support, and I knew that by filling out the form, she would get it.

Every child I flagged received at least one follow-up. None were overlooked.

Why the U.S. Falls Behind

Curious, I looked up “safeguarding in the USA.” Most results focused on national security. Adding “children” finally brought up child protection services—but it highlighted a critical difference. Every U.S. state runs its own system. Federal legislation like CAPTA offers guidance and funding, but the U.S. system is reactive, not preventative.

Unlike the UK, the U.S. lacks a formal, nationwide safeguarding structure. Every state has its own Child Protective Services (CPS), and the vastness of the U.S. creates a disadvantage for its children. Even though the U.S. mandates reporting, unlike the UK, this hasn’t improved outcomes. Back home, the system is patchwork. I remember a child I cared for in the U.S.—clearly abused—but the social worker said there wasn’t enough to ‘meet the threshold.’ I had no yellow form to fill, no guaranteed follow-up. I’ve watched too many children fall through the cracks.

In ten years of nursing in the U.S., I attended only two optional child protection trainings. In the UK, I received more education in one year than in my ten years in the U.S.—most of it mandatory.

It shows in the numbers: over the last five years, the UK averaged 52 child deaths by abuse or undetermined intent per year. In 2022 alone, the U.S. reported 1,990 such deaths. That translates to 2.7 deaths per 100,000 children in the U.S., versus 0.36 in the UK—a rate 7.5 times higher.

Let that sink in.

Being a child in the U.S. increases your risk of death by abuse compared to the UK.

Why? Yes, there’s less gun violence in the UK, and fewer families face overwhelming stress from healthcare or lack of paid leave. Most UK families get seven weeks of holiday to bond. But it’s more than that. It’s about education—everyone who works with children receives training. Permanency planning takes a back seat to what’s best for the child. The UK system is child-centred, proactive, and interconnected.

I got used to filling out the yellow form for bruises on non-mobile babies, or burns under the age of one. Part of the process is telling the parent they’ll receive a follow-up call. I learnt from the Welsh caseworker to phrase it supportively: “We just want to find out how we can help keep your child safe—maybe with a playpen, or help finding childcare.”

Looking back, I see the UK safeguarding system for what it is: a unified, protective network for its most vulnerable. I want to bring that concept back to the United States. To this day, every time I fill in that yellow form, I think of Victoria—and how a simple action might be the line between suffering and safety.