Josephine Gardiner opens a two-page report on what is being done to protect children from travelling terrible routes to abuse and death. It was a child, a girl of school age, who first raised the alarm back in 1992 about the occupants of 25 Cromwell Street, Gloucester.
She approached a passing policeman and told him of her unease about her friend, one of the West children, thus setting in motion the inquiry that uncovered murder, torture and child-abuse stretching back over three decades.
That the policeman took her seriously, and, later, that social workers believed the younger West children when they "joked" about their sister Heather being buried under the patio, is a credit to them and underlines the wisdom of the modern emphasis on listening to children - however unlikely their tales may sound. But in the aftermath of the verdict on Rosemary West last week, what many find hard to swallow is the length of time in which the couple were free to perpetrate their crimes without arousing the suspicions of relatives, neighbours, doctors, social workers - or teachers.
An independent inquiry commissioned by Gloucester County Council and conducted by the Bridge Child Care Consultancy largely exonerated the various agencies, concluding that no sane person could have imagined the obscenities that were going on behind the unassuming facade of the Wests' terraced house. "There is not a child protection service in the country that, on the basis of the information available, could have predicted that the family was at the centre of multiple murders."
While it is usually social workers rather than teachers who find themselves under the spotlight after cases of this kind, the West case has highlighted the importance of the teacher's role in child protection. According to Tony Saunders, Gloucester's principal education officer and member of the area child protection committee, the 10 West children, who attended a total of 12 schools over 26 years, appeared totally unremarkable.
"They were well turned out, neat, good attenders, their parents took an interest in their work - they seemed a very average family."
Fred Davies, Gloucester's deputy director of social services, adds that the children's general behaviour was equally conformist: "They were not truants, not in trouble with the police and not involved with drugs. At school they did not draw attention to themselves - for fear of the consequences at home. " Gloucester is currently working out how best to improve awareness of child abuse in its schools, particularly where it may not be obvious, and will be writing to all heads shortly.
More immediately, it seems likely that the West case will prompt a change in the rules on what schools should do when a child is suddenly removed. There has been much implied criticism of the fact that when eight-year-old Charmaine West was removed from her school in 1971, the parents' explanation that she had moved to London to be with her natural mother was taken at face value by the school. This was, and still is, perfectly normal.
Under the 1956 Pupils' Registration Regulations (updated this summer but unchanged in this respect), the child's name may be removed from the attendance register once the child has moved out of the area. The onus is on the child's new school to ask for records, although the head does have a duty, according to the Department for Education and Employment, to send on assessment details if the new school is known. Nigel Jones, the Liberal Democrat MP for Cheltenham, last week called for a debate on the regulations and asked Gillian Shephard, the Education and Employment Secretary, what her plans were.
"She phoned me back very quickly to say she thought that a review of the regulations was a very good idea." Officially, the DFEE now says it is "urgently examining" procedures.
Mr Jones is urging the Government to introduce a national system for tracking pupils when they move from one area of the country to another - one of the Bridge report's recommendations.
Gloucester has taken the initiative in writing to all its headteachers, including those at grant-maintained schools, asking them to inform the authority if there had been no request for records from another school. "This might have caused alarm bells to ring in the case of Charmaine West," says Tony Saunders, though he admits that there is some doubt about how the authority would proceed in these cases, and how far it should attempt to track former pupils.
The idea of checking up on families' movements is likely to be criticised on the grounds that it could intrude on civil liberties and generate red tape, but Nigel Jones was unperturbed - "better a bureaucratic nightmare than a child killed".
The West case has also drawn attention to the extreme vulnerability of young runaways and of all young people leaving or absconding from residential council care. Some of the Wests' victims were not missed. One of the murdered girls, Alison Chambers, was a former resident of a Gloucester children's home, Jordan's Brook House, as was the witness Miss A, who was abused at Cromwell Street as a young teenager but survived. Several of the other murder victims had been in council care.
The Gloucester inquiry however found no evidence that staff at Jordan's Brook House were aware of links with Cromwell Street. Fred Davies points out that matters have improved since the 70s - the 1989 Children Act imposes a duty on local authorities to help young people leaving care (who are usually only 16 or 17) adapt to independence. But agencies working with care leavers and the young homeless argue that in practice the system is not working and the amount and quality of help provided varies enormously between authorities.
According to Sue Fowler of First Key, an advisory service for the 10,000 teenagers who leave care each year, "the Children Act is very much open to interpretation - some councils have special projects and after-care teams, but it's still quite possible for young people to vanish into the void".
Sixty per cent of people leave care at 16, she said, after a childhood that is by definition troubled, and having left, "there's no going back, it's not like leaving the parental home where you can change your mind. Those in care are often seen as using up a valuable resource - they may want to come back but the bed is filled".
Seventy-five per cent of those in care leave school with no qualifications - compared to the national average of 8 per cent . Sara Noakes says that education tends to be seen as a low priority for pupils in care "Care is a holding operation, in which the individual is often forgotten. Children in care will also have changed schools five or six times. Nobody has a vested interest in them doing well, and they don't."
Adding to the grim statistics, a third of homeless 16 and 17-year-olds have a care background and 23 per cent of the adult prison population is ex-care.
Centrepoint, the charity for the young homeless, has called for urgent action on the part of local authorities to protect runaways, pointing out that there are only three refuges in the country for those that flee from home or care and that private landlords providing accommodation for young people are not regulated.
In a report, drawn up jointly with the trust established after the disappearance of Suzy Lamplugh, it points out that there is still no agreed definition of what constitutes a missing person and that "there is a lack of research to allow agencies to assess the problem."
In London in 1994-5, 5,746 children under the age of 14, and 15,705 young people aged 14-18 were reported missing. Nearly 170 cases remain unresolved.