baby p case study summary

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Peter Connelly Serious Case Review reports published

Children's minister Tim Loughton comments on the publication of the two serious case review (SCR) reports into the death of Peter Connelly.

The Government is today fulfilling its commitment to publish the two Serious Case Review (SCR) overview reports into the tragic death of Peter Connelly, in order to restore public confidence and improve transparency in the child protection system.

The SCR reports have both been carefully and appropriately redacted and anonymised to protect the privacy and welfare of vulnerable children and their families.

Children’s Minister Tim Loughton wants today’s publication of the Peter Connelly reports to help enable

• genuine lessons to be learned
• transparency, to restore public confidence, and
• the identification of everyone’s roles and shared responsibilities.

Children’s Minister Tim Loughton said:

Today everyone can see and understand the events that led to Peter Connelly’s horrific death. The publication of both Peter Connelly reports means that across the country and across the child protection profession, full lessons can be learned and widely applied.

The Government’s commitment to publish full SCR overview reports has always been about transparency so that vital information is made available, so that agencies can be held to account and lessons properly learned. The reports have details of the events which are shocking to read but are necessary to publish in order to learn from them.

The publication of these reports is not about apportioning blame but about allowing professionals to understand fully what happens in each case, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future. I welcome the progress that Haringey and local partners have made over the past two years and it is essential that this progress continues.

We have taken a great deal of care to prepare these sensitive and complex reports for publication in order to protect the privacy and welfare of vulnerable children and their families.

After two years of high-profile reporting, I want today’s publication of the Peter Connelly reports to bring some form of closure, so everyone - family and professionals - involved in this tragic case has the chance to move on.

Alongside the launch of the Munro Review on 10 June, Children’s Minister Tim Loughton committed to publishing - by applying the new criteria of publication - five specific Serious Case Reviews, including the two Peter Connelly reports, with identifying details removed. The minister also confirmed, as stated in the Coalition Government agreement, that the overview reports and executive summaries of all new SCRs initiated from 10 June 2010 should be published.

Chair of Haringey Safeguarding Children’s Board, Graham Badman, said:

The tragic death of Peter Connelly has quite properly caused a fundamental re-appraisal of child protection services in Haringey and throughout the country. If Peter is to have a legacy, it is that other children are now safer as a consequence of the honest analysis of events that led to his death, and the embedding in practice of the lessons learned.

Services in Haringey have improved dramatically but the LSCB will continue to be vigilant in both auditing and seeking improvement in the management and conduct of all services charged with child protection. The publication of the full Serious Case Review marks an end point but also demonstrates the integrity and willingness to change of all services that contributed.

Haringey’s Cabinet Member for Children & Young People, Cllr Lorna Reith, said:

We have accepted that things went badly wrong with our child protection services back in 2007 and have apologised unreservedly for our shortcomings and mistakes. Baby Peter’s death could and should have been prevented.

Since publication of the Serious Case Reviews, whose recommendations we have implemented in full, it has been our top priority to bring about substantial change and improvement to children’s safeguarding in the borough.

The recent unannounced inspection by Ofsted - which took place in August and reported in September - was tangible proof that significant progress has been made, but it is our responsibility to remain vigilant in Baby Peter’s memory and never stop improving.

The SCR overview reports relating to Peter Connelly were written by independent authors commissioned by the Haringey Local Safeguarding Children Board. The only editing undertaken by the Department prior to publication is the redaction of information that it is not appropriate to put into the public domain. An explanation of the redactions is set out in the beginning of each report.

Notes to editors

• The first SCR was commissioned in August 2007 by Haringey LSCB, under the chairmanship of Sharon Shoesmith, and the executive summary was published by the LSCB in November 2008. This SCR was evaluated as ‘inadequate’ by Ofsted.
• In December 2008, the then Secretary of State for Children, Schools and Families directed the appointment of a new LSCB Chair, Graham Badman, and asked the Haringey LSCB to begin a new SCR on the case of Peter Connelly. This second SCR was evaluated as ‘good’ by Ofsted and the executive summary was published in May 2009.
• The Coalition Government confirmed on 10 June 2010 its intention that the previously unpublished overview reports (together with the executive summary) of all of these SCRs would be published, appropriately redacted and anonymised. Birmingham published the SCR overview report relating to Khyra Ishaq on 27 July 2010.
• The process of redacting the overview reports has involved: * considering the welfare of children involved in the case * comparing the executive summary already in the public domain, with the corresponding overview report; no information that is included in either of the executive summaries has been redacted * considering the extent to which information in the overview reports is capable of being used to identify living individuals whose identity is not already common knowledge * considering whether information that is by its nature sensitive, personal data under the Data Protection Act 1998 (for example, because it is information about a person’s physical or mental health or condition, his/her sexual life, or the commission or alleged commission by him/her of an offence) is likely to have already been made public (for example, as part of the criminal trials), and whether its inclusion in the reports is necessary to give a complete picture of events * redacting personal data or information that would breach reporting restrictions imposed by the Court, and * redacting any personal or sensitive personal data, including clinically confidential information, that has not already been published and which cannot be justified as necessary or relevant, bearing in mind the overall purpose of publishing the overview reports.
• Only redactions that are strictly necessary have been made and the final versions of the reports to be published will allow the lessons from this tragic case to be learned as widely and thoroughly as possible.
• The SCR overview reports for Peter Connelly are available for download from this page: * First Serious Case Review overview report relating to Peter Connelly dated November 2008. * Second Serious Case Review overview report relating to Peter Connelly dated March 2009.
• The following related documents are also available to download from this page: * The executive summary for the first Serious Case Review overview report dated November 2008 relating to Peter Connelly. * The executive summary for the second Serious Case Review overview report dated February 2009 relating to Peter Connelly. * A copy of the letter of 10 June 2010 sent to DCSs and LSCB chairs by Tim Loughton, Parliamentary Under-Secretary of State for Children and Families, to confirm new arrangements and amended guidance for publication of SCRs.

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The Story of Baby P: Setting the Record Straight

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Keith Popple, The Story of Baby P: Setting the Record Straight, The British Journal of Social Work , Volume 45, Issue 3, April 2015, Pages 1069–1071, https://doi.org/10.1093/bjsw/bcv011

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The horrendous cruelty, torture and abuse to and deliberate neglect of Peter Connelly followed by his appalling death in north London at the age of seventeen months in August 2007 are etched on the minds of social workers practising in England and elsewhere. This dreadful incident continues to impact on the careers on both present and future generations of social workers, as it has led to changes in the delivery of qualifying social work education and of social work practice with children and families in England.

Briefly, and to remind international readers, Peter suffered from more than fifty injuries over an eight-month period before his death. Although during this period Peter was seen again and again by professionals from a number of public agencies including the local authority Haringey Children's Services and the health professionals, he was not removed from his abusive home life to a place of safety. Following the Old Bailey conviction and imprisonment of Peter's mother Tracey Connelly, her partner Steven Barker and Barker's brother Jason Owen, a number of statutory reviews of the case and a national review of social work took place, which together with a debate in the House of Commons revealed major concerns in the way that the professions had dealt with Peter.

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The Story of Baby P: Setting the Record Straight

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• > The Story of Baby P
• > Appendix: Key reviews and reports

Book contents

• Frontmatter
• List of photo credits
• Foreword by Patrick Butler
• Introduction
• one The life and death of Peter Connelly
• two The ‘Baby P story’ takes hold
• three The frenzied media backlash
• four The influence of reviews and reports
• five The story’s damaging impact
• six The continuing legacy of the ‘Baby P story’
• Appendix: Key reviews and reports

Published online by Cambridge University Press:  15 April 2023

Reviews directly relating to ‘Baby P’ case

First serious case review (SCR) report (commissioned August 2007)

Haringey Local Safeguarding Children Board (2008) Serious case review ‘Child A’ , Executive Summary, November, London: Department for Education (DfE) [DfE (2012) ‘Publication of the two Serious Case Review overview reports – Peter Connelly’, updated 12 July 2012 (www.education.gov.uk/a0065483/serious-case-review)].

Sibert and Hodes review report (commissioned January 2008)

Sibert, J. and Hodes, D. (2008) Review of child protection practice of Dr Sabah Al-Zayyat , London: Great Ormond Street Hospital NHS Trust.

Individual management review prepared on behalf of NHS London (commissioned December 2008)

Lowton, A. and Bos, S. (2009) An individual management review into the care of PC on behalf of NHS London , February, London: Verita.

Second serious case review (SCR) report (commissioned December 2008)

Haringey Local Safeguarding Children Board (2009) Serious case review ‘Child A’ , Executive Summary, May; full report published 26 October 2010, London: Department for Education.

Care Quality Commission (CQC) Review of NHS involvement with Peter Connelly (commissioned December 2008)

CQC (2009) Review of the involvement and action taken by health bodies in relation to the case of Baby P , May, London: Care Quality Commission.

Reviews relating Haringey Children’s Services

Haringey Joint Area Review (2006) London Borough of Haringey Children’s Services Authority Area, Joint Area Review , London, Ofsted.

Ofsted (2007) 2007 Annual performance assessment of services for children and young people in the London Borough of Haringey , 26 November, London: Ofsted.

Haringey Joint Area Review (commissioned November 2008)

Ofsted, Healthcare Commission and Her Majesty’s Inspectorate of Constabulary (2008) Joint area review: Haringey Children’s Services Authority Area , November.

Haringey further Joint Area Review (commissioned December 2008)

Ofsted (2009) Inspection of progress made in the provision of safeguarding services in the London Borough of Haringey , 3 July.

Other serious case review reports

Maria Colwell

Department of Health and Social Security (1974) Report of the Inquiry into the care and supervision provided in relation to Maria Colwell , London: HMSO.

Victoria Climbié

Lord Laming (2003) The Victoria Climbié Inquiry , Norwich: The Stationery Office.

Other relevant reports

Conservative Party Commission on Social Workers (2007) No more blame

game: The future for children’s social workers , London: The Conservative Party.

Lord Laming (2009) The protection of children in England: A progress report , House

of Commons, Norwich: The Stationery Office.

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• Ray Jones , Kingston University, London and St George's Hospital Medical School, University of London
• Book: The Story of Baby P
• Online publication: 15 April 2023
• Chapter DOI: https://doi.org/10.46692/9781447316305.009

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The lessons of Baby P

Although the case of Baby P, killed at the age of 17 months by his mother, her boyfriend and a lodger has provoked a national controversy, for me it is very close to home. I live near to where Baby P lived in the London borough of Haringey, whose officers have been held to blame, and I have long been involved in child protection work as a GP in the neighbouring borough of Hackney.

My immediate feelings of horror and outrage at the savage abuse suffered by Baby P and sympathies for his wider family, were soon followed by concerns for the doctors and other professionals involved, and the familiar sentiment of ‘there but for the grace of God …’. These concerns were particularly reinforced by vivid memories of a case with many similarities in our practice more than a decade ago.

In this case a baby of a similar age to Baby P was killed by his mother's boyfriend. The peculiar intimacy of the fatal blow — inflicted by head-butting — expressed both the ferocity and the barbarity of the assault, in a way strikingly similar to the account of Baby P's fractured spine and multiple injuries. The man who was convicted in our case (of previous good character and sound mental health) later conceded that he knew from the moment he met this baby he was destined to kill him. As Andrew Cooper, professor of social work at the Tavistock, observes in a thoughtful commentary, ‘the treatment of Baby P reminds us that there are people whose minds, actions, motives, and ways of relating to others seem incomprehensible’. 1 He also notes that research into serious case reviews of children killed or injured between 2003 and 2005 revealed that nearly 90% of the most dangerous cases were not on the child protection register. He counsels against concluding from such cases that the system is failing, because ‘arguably’, it was ‘never designed to deal with these extremes of human behaviour’.

The inquiry into our case came to the same banal conclusions as every other such inquiry over several decades: everybody was to blame, there was a lack of inter-agency coordination and everybody should try harder in future. In fact, as I observed in a response to the official report, the inquiry confirmed that, even though approved procedures had been followed to the letter, it was clear that nobody could have anticipated and prevented what happened. The striking difference from the Baby P case — reflecting the highly arbritrary and irrational character of the recent furore — was that this one attracted little local publicity and no national interest. Hence it was not followed by the sort of witch-hunting and political posturing that has accompanied the recent case, leading to numerous sackings and resignations in Haringey.

The vituperative media response to the death of Baby P reveals popular prejudices against people who live in relatively deprived inner-city areas and an inability to acknowledge the extremes of depravity of which human beings are capable. The scapegoating of the social workers and other professionals reflects the need to find somebody to blame and the wishful thinking that all cases of extreme cruelty to children can be prevented. It also serves to justify the extension of professional intervention into all aspects of child development in ways that will not improve protection against abuse but may further undermine parental confidence and family cohesion. 2

‘Think dirty’ is the prevailing advice to doctors and health visitors and others who are in day-to-day contact with young children and their families. Inflated estimates of the prevalence of child abuse encourage suspicion and mistrust between professionals and parents. 3 But working on the presumption that every child who comes into the surgery may be at risk of becoming another Baby P is not conducive to good relations with parents, or, ultimately, to the interests of children.

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Analysis: The Badman review of the Baby P case

There were relatively few revelations in today's yesterday's Badman review of the Baby P case. The difference from the previous review, which had been deemed "inadequate," is of interpretation.

The original serious case review summary, published in November 2008, said there had been procedural failings and errors of judgment, but none on their own "were likely to have enabled further responses that might have prevented the outcome".

The Badman review is clear that this was too generous a reading: Peter's death "could and should have been prevented". He could reasonably have been taken into care after the first serious incident, in December 2006, and on several occasions afterwards had professionals been more diligent.

The original report explains – but does not excuse – the failures to take Peter from his family in the context of the behaviour of his mother: she was frequently co-operative, with an open manner, and keen to please, so agencies built up a trust in her.

They saw Peter's injuries as resulting from lack of parental supervision coupled with his observed tendency to "throw his body around and headbutt family members and physical objects."

This perspective framed the way professionals viewed Peter's subsequent injuries, the original report concluded. Wrong-footed by the mother, and seemingly never quite getting enough solid evidence to warrant a criminal charge or issue care proceedings, they effectively gave her the benefit of the doubt. The overwhelming sense of the first review is of well-meaning professionals struggling to bring a clear focus to an infernally complex, chaotic and constantly shifting situation.

Badman is scathing of this. He argues that social workers in particular were too timid. Professionals "over-identified with the parent", and were even bullied by her.

While the original report gives no clear picture of the mother, Badman portrays her as an arch-manipulator, subverting the professionals, "a dominating and forceful personality", eminently capable of intimidation.

Badman also rejects the assertion that the agencies could not have known about the malign presence of the boyfriend. More diligence would have sniffed him out.

Badman's interpretation, fashioned with access to more information, is at times clear-sighted in spotting of unforgiveable errors, at others unforgiving of understandable human failings.

Professionals should be more interventionist: if they suspect abuse, they should act on it, even if they are proved to be mistaken. "Better that than the harm the child will experience."

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Systemic failings in NHS contributed to death of Baby P

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• Jacqui Wise

The NHS must accept its share of responsibility for the death of Baby P, the 17 month old boy who died at the hands of his mother, her partner, and their lodger, the new independent regulator of health and social care in England has said.

A report by the Care Quality Commission found systemic failings in the health care provided by NHS trusts to Baby P, whose first name has been revealed as Peter.

Excluding his birth, Peter had 34 contacts with health professionals at North Middlesex University Hospital NHS Trust and Haringey Teaching Primary Care Trust, in north London. Paediatric staff in these hospitals was provided by Great Ormond Hospital for Children NHS Trust.

The commission said it was concerned that the boards of all the trusts with which the baby had contact had previously declared themselves as complying with all the core standards related to safeguarding children.

The commission’s chief executive, Cynthia Bower, said, “There were clear reasons to have concern for this child, but the response was simply not fast enough or smart enough. The NHS must accept its share of …

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IMPACT CASE STUDY: The story of ‘Baby P’

by Ray Jones 23rd July 2019

It is just over ten years since the launch of the media story and storm about the death of a little boy who came to be called ‘Baby P’ . He was killed in August 2007 but it was in November 2008 that his mother, her boyfriend and the boyfriend’s brother were each convicted of ‘causing or allowing ‘Baby P’s’ – Peter Connelly’s –death.

The media frenzy which followed was led by The Sun newspaper and its editor, Rebekah Brooks, supported by her Cotswold neighbour and friend, David Cameron. At the time he was leader of the Conservative Parliamentary opposition and he made a political issue out of Peter’s death, blaming Labour-controlled Haringey council and the social workers it employed.

I am a social worker and a former Director of Social Services. From 2008 until 2016 I was Professor of Social Work at Kingston University and St George’s, University of London. Each week I also oversaw children’s services improvement in areas rated by Ofsted as not performing well.  My location in south London and my experience led me to be frequently called upon by television, radio and the print press to comment on the ‘Baby P’ and related stories (the record was 14 television and radio interviews on one day between 11:00 and 18:30 on one day).

The Baby P story targeted and vilified, in particular, Haringey’s director of children’s services, Sharon Shoesmith, and the social worker and her team manager who had sought to help the Connelly family and to improve the care of the Connelly children. They worked hard and were seeking to tackle the neglect the children were experiencing. It was only in the weeks before Peter died, which was after the boyfriend’s brother had moved to live with the family (unknown to the social worker and other professionals involved with the family), that neglect escalated quickly to physical violence and abuse.

The distorted media’s Baby P story of incompetent social workers and managers led to them losing their jobs and being threatened. The social worker had to move home several times. Sharon Shoesmith, on the advice of the police, had to have a secure safe room built within her flat.

Through my media work, I became more and more concerned about how the Baby P story was being miss-told, about the real dangers being created for the social workers, their managers and their families (who were also threatened), and how throughout the UK it made it harder to protect children due to difficulty in recruiting social workers, health visitors and paediatricians.

My increasing knowledge and concerns about what was happening led me to write The Story of Baby P: Setting the Record Straight, largely written in the summer of 2012. The mainstream publishers I contacted would not publish the book and I was delighted when Policy Press took it on board. It was not, however, published until June 2014, after the phone hacking trial in which Rebekah Brooks was one of the defendants.

How has the book made a difference? What impact has it had?

Firstly, it has provided a correction to the story created and peddled by The Sun and others. In addition to it selling 8,000 copies it was used in preparing a 90 minute BBC One television documentary broadcast during prime time in October 2014. It has formed the basis of over 40 conference presentations I have given to what must be more than 6,000 social workers, but also police officers, lawyers, doctors, health visitors, midwives and teachers. I have also given several public lectures attended by a wider public, plus book signings.

The book and the information within it has  been referenced in oral and written evidence to Parliamentary Select Committees and it has been covered by a range of national and international media, including Russia Today, a South Korean national newspaper and a German magazine.

With an expanded and updated edition published in 2017, it has tracked the continuing impact of the media’s Baby P story with more children being caught in the child protection net. This has happened at the same time as politically-chosen austerity since 2010 has targeted poor families and public services leading to big cuts in the help which can be given to children and families. This tracking of the changes has been reported by broadsheet and tabloid newspapers as well as on radio and television. I still receive requests today from the media (one this morning, as I write this blog, from BBC Radio Four’s The World at One) to comment on what has happened to children’s social services and child protection over recent years.

The book has had an impact for those who gave their professional lives to help and protect children, but who themselves were the subject of harassment and hatred because of the skewed story promoted by The Sun and others. When I wrote the book I had not met those who were placed in danger by the campaign of hostility led by Rebekah Brooks. I did not want to add any more intrusions into their lives.

In the months prior to publication, Patrick Butler of The Guardia n, who wrote the Foreword to the book, helpfully and appropriately alerted Sharon Shoesmith to its forthcoming publication. I subsequently have met with Sharon, and with Maria and Gillie, the social worker and her team manager. They are each impressive. Wise, caring and with substantial former careers in social work and education, they were and should be much respected. Their commitment to help children was ended by the media coverage. They have not been able to continue their careers and work.  But they have found it helpful, as reported in Community Care magazine , that they and their families, friends and colleagues now have a public record of what actually happened and about the press and political opportunism which generated the hatred they have experienced and which has hindered the care and protection of children. It has left a legacy of a children’s social services system in England which has moved beyond crisis to, in some areas, collapse.

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Baby P: Poor practice caused protection failure

The failure to protect Baby P was because of poor practice by health professionals, social workers, police and lawyers rather than systematic breakdown, a serious case review found. Professionals in the London borough of Haringey saw the boy 60 times before his death, caused by his mother and stepfather, and the inquiry found agencies communicated with each other and procedures were largely followed. However, there was a poor flow of information in some areas. Despite being on the child protection register for the final eight months of his life, there was a “pervasive belief” that the 17-month-old boy’s injuries were accidental. Professionals believed mother Few professionals challenged the mother’s account that these were the result of an “active” child who often bumped into and head-butted things, and only considered that she was guilty of poor supervision. Sharon Shoesmith, c hair of Haringey local safeguarding children board and director of Haringey children’s services, said: “ The mother seemed to be co-operating with us: taking the child to the doctor’s when he was ill, seeking help.” Flawed paediatric assessment However, only one mistake was highlighted as “critical” in the failure to identify the abuse. This was made by the paediatrician who examined the boy 48 hours before he died. By this stage the child had suffered serious injuries, including fractures to his ribs and spine, but the paediatrician’s assessment recorded that he was “miserable” with a viral infection. The review found that expert medical opinion “ concluded that a diagnosis of abuse should have been made at that point”. Care threshold ‘not met’ A week before the boy died, social workers were advised by Haringey Council’s lawyers that the threshold for launching care proceedings had not been met. The risk was compounded by the presence of the boy’s stepfather, who lived in the house for up to six months without the knowledge of the child protection team. The report made 45 recommendations aimed at agencies covering six professional areas. These included inviting paediatricians to child protection conferences, and training for managers supervising professionals involved in safeguarding work, ensuring they were “vigilant” and “open and inquisitive”. Guilty verdicts Yesterday the stepfather, 32, and a lodger, Jason Owen, 36, were convicted at the Old Bailey of causing of allowing Baby P’s death in August last year. His mother, 27, had already pleaded guilty to the same charge. More information Haringey statement and serious case review Carespace Is the Baby P case symptomatic of a wider problem? Have your say on CareSpace Related articles Victoria Climbié Foundation demands public inquiry into Haringey abuse case Baby P case prompts government to commission second Laming review National media coverage News round-up: Baby P

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Timeline: The shocking events that led to death of Baby P

2006 March 1 - Peter Connelly is born to Tracey Connelly. November - Connelly's boyfriend, Steven Barker, moves into her home. This is kept from police and social workers. December 11 - Peter is taken to Whittington Hospital in Archway, north London, with bruises on his head, nose, chest and right shoulder. December 19 - Police arrest and interview Connelly on suspicion of assaulting her son. She denies injuring him. December 22 - Peter is placed on the child protection register.

2007 January - Peter is returned to his family. June - Barker's brother, Jason Owen, moves into the home with a 15-year-old runaway he describes as his girlfriend. July 30 - Maria Ward, a social worker with Haringey Council in north London, makes a pre-arranged home visit. She misses injuries on Peter's face and hands after he is deliberately smeared with chocolate to hide them. July 31 - Police hand reports to the Crown Prosecution Service, including statements from two doctors saying Peter's bruising was suggestive of "non-accidental" injury. Prosecutors decide there is not enough evidence to bring a case. August 1 - Peter is taken to a child development clinic at St Ann's Hospital in Tottenham, north London. Paediatrician Dr Sabah Al-Zayyat decides she cannot carry out a full check-up as the boy is "miserable and cranky". A post-mortem examination later reveals Peter had probably already suffered a broken back and fractured ribs by this point. August 2 - Police tell Connelly she will not be prosecuted. That evening, the child receives the fatal last blow to the mouth, knocking his tooth out. August 3 - A 999 call is made at 11.36am. Four minutes later paramedics find Peter lying in his blood-spattered cot. He is pronounced dead on arrival at hospital. An attempt has been made to cover up the crime, with the child's clothes and bedding removed and dumped.

2008 November 11 - Owen and Barker are found guilty at the Old Bailey of causing or allowing the death of a child. Connelly has already pleaded guilty to the same offence. November 12 - Children's Secretary Ed Balls orders an urgent review of Haringey Council's children's welfare services. November 21 - The General Medical Council suspends Dr Al-Zayyat's registration as a doctor. December 1 - Inspectors deliver a damning report on Haringey children services to Mr Balls, who describes their findings as "devastating". Haringey Council's leader, George Meehan, and cabinet member for children and young people, Liz Santry, resign. Mr Balls removes Sharon Shoesmith as the local authority's director of children's services, but she remains suspended on full pay. December 8 - Ms Shoesmith is sacked by a panel of councillors with immediate effect and told she will not receive any compensation.

2009 January 12 - A panel of Haringey councillors rejects Ms Shoesmith's appeal against her dismissal. February 17 - The General Medical Council suspends from practice family GP Dr Jerome Ikwueke, who twice referred Peter to hospital specialists after becoming concerned about suspicious marks on his face and body. March 6 - Ms Shoesmith lodges an employment tribunal claim for unfair dismissal against Haringey Council and launches an application for judicial review against the council, Mr Balls and Ofsted. March 12 - A review of child protection in England, commissioned after Peter's death and led by Lord Laming, finds that too many authorities have failed to adopt reforms introduced following the 2000 Victoria Climbie tragedy. April 29 - Haringey Council sacks four key social workers, including deputy director of children and families Cecilia Hitchen and Ms Ward. May 1 - Barker is found guilty at the Old Bailey of raping a two-year-old girl on Haringey's at-risk register. Connelly is cleared of cruelty to the girl. May 13 - The NHS is criticised by health watchdog the Care Quality Commission for "systemic failings" in the care given to Peter before his death. May 22 - Judge Stephen Kramer describes Connelly as "manipulative" and "calculating" as he jails her indefinitely with a minimum term of five years for her part in her son's death. Barker is jailed for life with a minimum of 10 years for raping the two-year-old girl and given a 12-year term to run concurrently for his "major role" in Peter's death. Owen receives an indefinite sentence with a minimum term of three years. July 3 - Inspectors warn that Haringey Council is still not protecting all vulnerable children from abuse and has made only limited progress in tackling areas of weakness. August 11 - Connelly and Barker are named for the first time after a court order protecting their anonymity expires.

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Baby P: Lessons To Be Learned

May 12, 2013 //  by  Admin

What can schools learn from the Baby P case? Jenni Whitehead examines the report on Haringey children’s services and gives advice on how to prepare for unannounced inspections.

Following the conviction of two men and a woman for causing or allowing the death of Baby P, the secretary of state for children, schools and families, Ed Balls, instructed Ofsted, along with the Healthcare Commission and the chief inspector of constabulary, to carry out an urgent review of services to children and young people in Haringey, with particular regard to safeguarding. This joint area review has since been published.

In a press statement given on 1 December 2008, Mr Balls said:

‘The whole nation has been shocked and moved by the tragic and horrific death of Baby P. All of us find it impossible to comprehend how adults could commit such terrible acts of evil against this little boy. And the public is angry that nobody stepped in to prevent this tragedy from happening.

‘I want to say very clearly at the outset: social workers, police officers, GPs, health professionals, all the people who work to keep children safe, do a very difficult job, often in really challenging circumstances – all around the country and in particular in Haringey.

‘They make difficult judgements every day that help to keep children safe – and many of them are unsung heroes.

‘But they must also be accountable for their decisions. And where things go badly wrong, people are right to want to know why and what will be done about it. In the case of Baby P, things did go tragically wrong.’

The joint area review expresses serious concerns about the leadership and management of safeguarding, frontline practice and the supervision of frontline staff within children’s services in Haringey (see box). Its criticisms appear to be based on how Haringey measures up to the recommendations made in Lord Laming’s report published following the death of Victoria Climbié.

As a consequence of the joint area review, both the leader of Haringey Council and the lead member for children’s services announced their resignations. Ed Balls has directed Haringey to appoint John Coughlan as director of children’s services and the council has sacked the former director, Sharon Shoesmith, without payment of compensation.

The serious case review carried out by Haringey and published on the same day as the conviction (see Protecting Children Update , November) is described in the joint area review as inadequate. According to Ofsted’s first national evaluation of serious case reviews there is variable quality across the country in conducting such reviews. ( Learning Lessons, Taking Action ).

As a result of this finding Ed Balls announced that he would be asking ‘each local safeguarding children board responsible for a serious case review which has been judged inadequate to convene a panel to be chaired by an independent person to reconsider the review.’

Ed Balls has announced that Ofsted will carry out annual reviews of children’s services across the country. Reading the main findings of the joint area review gives us an idea as to what Ofsted will be looking for in such reviews. The main findings are given in the box above, and its recommendations are listed in the box below. Schools will be included in such reviews and as the main referring agency need to take account of the joint area review.

How does this affect education staff?

The following points are made to help schools check their current child protection practice in light of criticisms made by the joint area review in Haringey.

Making referrals

• Make sure all staff are aware of child protection procedures. If you are the named person, make sure that staff are passing on their concerns to you promptly.
• If you are asked to monitor a situation, or if you are asking members of staff to monitor, make sure that there is a clear plan. Agree how long the monitoring period will be. Be clear about what you or your staff are looking out for. Make sure you have systems in place in respect of recording throughout the monitoring period. Make sure that records are kept securely and not within the child’s curriculum file.
• If you make a child protection referral, make sure that you inform children’s social care of any past concerns or referrals. Research shows that where incidents are described in isolation there is a danger that they will be treated as discrete events. Remember it is often the relationship between incidents that is crucial in understanding the level of risk to the child.
• Follow up your referral in writing. (Many LAs have a child protection referral form for this purpose, check with your LA’s designated officer.)
• Be prepared to stand your ground. If in your professional judgement the situation warrants a child protection referral as opposed to a CAF assessment, stand firm. CAF assessments should not be used for child protection cases, they require a much more specialist assessment.
• When making a referral give as much detail as you can about the family make-up. If you know that people who are not part of the family are living in the household include this information in your referral. If children or adults in the family are known by more than one name make sure this information is given at referral.
• Keep records securely. If teachers and other staff make handwritten notes as part of their monitoring, keep the handwritten note and the typed-up version together.
• Keep records in a chronological order. Make sure all children in the family are acknowledged in your record keeping and where concerns are raised about one child, check with members of staff whether there are any concerns for the other children; if so, include this information in your referral.

Supervision

• If you are responsible for the management of staff involved in child protection work, ensure that supervision is offered on a regular basis and that it includes opportunities to address concerns about safeguarding.
• Some schools employ social workers. Be aware that registered social workers are entitled to regular supervision by an appropriate level of management.
• Ensure staff with child protection responsibilities are given adequate time to make case records. If you need to record an event, do so as soon as possible after it happens; if you are finding it hard to find time to record, take this up in supervision.

Named persons must refresh their child protection training every two years. All other education staff must refresh every three years. Check with your safeguarding board how you can access training.

Working together

The joint area review criticized the lack of collaboration and communication between agencies, and specific reference was made to agencies not being present at strategic meetings, case conferences and core group meetings. Such meetings provide a forum to share information and decision-making.

Working together successfully depends on the development of professional relationships across agencies. Strategic meetings can help to develop relationships but it is also useful to meet other professionals in less formal settings. Consider inviting social care workers into school to meet staff informally or to give a presentation to a staff meeting about their work.

• Make sure strategies are in place to ensure that members of staff are able to attend child protection meetings.
• In respect of case conferences, remember that it is important that the person who attends on behalf of school is in a position to make decisions and to commit resources.
• If the named person feels that the class teacher is the most appropriate person to attend, make sure that the case is discussed thoroughly beforehand.
• Schools are asked to prepare a report for the case conference. This needs time to prepare and schools are usually asked to send the report in before the conference. Also bear in mind that parents are invited to case conferences and children’s social care will want to go through any reports submitted to the conference with the parents beforehand.
• If you disagree with the recommendations made at a case conference, ask for your opinion to be minuted, otherwise it will be presumed that you agree.
• If you cannot attend the conference and cannot send a representative, let the chair of the conference know and request that the minutes be sent to you. Make sure that you check the minutes as a recommendation may have been made in your absence that you cannot commit or agree to. If this happens, contact the chair and ask for the conference notes to be amended.
• In respect of core groups, make sure appropriate staff are able to attend. Core groups demand consistency in membership. Core group meetings are where professionals and parents can really address the child protection plan. The first core group meeting date is usually set at the end of the case conference. This first meeting is absolutely key in keeping up the momentum from the case conference where parents will have been confronted with the issues and the need to change. If there is a long delay between case conference and first core group meeting the case can slip into drift, parents interpreting the delay as a message that issues raised at the case conference were perhaps not as serious as the conference had suggested.
• Strong multi-agency membership of core groups make it harder for deviant parents to play one agency against the other and ensures that all concerned are kept up to date with the progress of the case.
• Participation in core group meetings is expected; if you are asked to be a member try to get dates for future meetings set early to ensure that school can plan cover for your attendance.
• If the child protection plan is not bringing about the expected changes in how the parents respond to their children’s needs the case conference should be reconvened, if necessary before the date set for review.

Ongoing vigilance

The joint area review criticized the level of ongoing communication between all agencies. I have mentioned above some of the ways agency collaboration can be improved. However, it takes will on all parties to continue working together practice. One of the issues highlighted in the joint area review is that agencies did not keep each other up to date in respect of changed circumstances in the family or in terms of change of worker. On the first point, never presume that the parents have told the social worker what they have told you – always check. Parents may innocently tell one member of the professional network about a change in circumstance or an incident, presuming that in telling one professional they are telling all those working with them. On the other hand, the parent who is intent on covering up incidents may give one story to one professional and another story to someone else.

Child Protection in schools

As you are aware, schools have a statutory duty to safeguard and promote children’s welfare; make sure your child protection policy is regularly reviewed and that your governors are supportive of the child protection structures and processes. If you have concerns about how a case is progressing, seek advice from your education designated officer, the senior case worker for the case or your local safeguarding board.

Read Joint Area Review Haringey Children’s Services Authority Area

Ed Balls has announced that Ofsted will carry out annual reviews of children’s services across the country... Schools will be included in such reviews

We are unable to publish reader comments about individual child protection concerns on this website. If you are worried about a child please call the NSPCC Helpline on 0808 800 5000 for help and advice. Alternatively you can contact your Local Safeguarding Children Board (LSCB) through your local council.

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The lessons of Baby P

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Although the case of Baby P, killed at the age of 17 months by his mother, her boyfriend and a lodger has provoked a national controversy, for me it is very close to home. I live near to where Baby P lived in the London borough of Haringey, whose officers have been held to blame, and I have long been involved in child protection work as a GP in the neighbouring borough of Hackney.

My immediate feelings of horror and outrage at the savage abuse suffered by Baby P and sympathies for his wider family, were soon followed by concerns for the doctors and other professionals involved, and the familiar sentiment of ‘there but for the grace of God …’. These concerns were particularly reinforced by vivid memories of a case with many similarities in our practice more than a decade ago.

In this case a baby of a similar age to Baby P was killed by his mother's boyfriend. The peculiar intimacy of the fatal blow — inflicted by head-butting — expressed both the ferocity and the barbarity of the assault, in a way strikingly similar to the account of Baby P's fractured spine and multiple injuries. The man who was convicted in our case (of previous good character and sound mental health) later conceded that he knew from the moment he met this baby he was destined to kill him. As Andrew Cooper, professor of social work at the Tavistock, observes in a thoughtful commentary, ‘the treatment of Baby P reminds us that there are people whose minds, actions, motives, and ways of relating to others seem incomprehensible’. 1 He also notes that research into serious case reviews of children killed or injured between 2003 and 2005 revealed that nearly 90% of the most dangerous cases were not on the child protection register. He counsels against concluding from such cases that the system is failing, because ‘arguably’, it was ‘never designed to deal with these extremes of human behaviour’.

The inquiry into our case came to the same banal conclusions as every other such inquiry over several decades: everybody was to blame, there was a lack of inter-agency coordination and everybody should try harder in future. In fact, as I observed in a response to the official report, the inquiry confirmed that, even though approved procedures had been followed to the letter, it was clear that nobody could have anticipated and prevented what happened. The striking difference from the Baby P case — reflecting the highly arbritrary and irrational character of the recent furore — was that this one attracted little local publicity and no national interest. Hence it was not followed by the sort of witch-hunting and political posturing that has accompanied the recent case, leading to numerous sackings and resignations in Haringey.

The vituperative media response to the death of Baby P reveals popular prejudices against people who live in relatively deprived inner-city areas and an inability to acknowledge the extremes of depravity of which human beings are capable. The scapegoating of the social workers and other professionals reflects the need to find somebody to blame and the wishful thinking that all cases of extreme cruelty to children can be prevented. It also serves to justify the extension of professional intervention into all aspects of child development in ways that will not improve protection against abuse but may further undermine parental confidence and family cohesion. 2

‘Think dirty’ is the prevailing advice to doctors and health visitors and others who are in day-to-day contact with young children and their families. Inflated estimates of the prevalence of child abuse encourage suspicion and mistrust between professionals and parents. 3 But working on the presumption that every child who comes into the surgery may be at risk of becoming another Baby P is not conducive to good relations with parents, or, ultimately, to the interests of children.

• © British Journal of General Practice, 2009.
• The Lancet, UCL Institute of Child Health, RCPCH

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Baby P report

Baby P, also known as Baby Peter, was a 17-month-old boy who died following months of abuse, despite being on Haringey Council’s child protection register. Haringey Council was also responsible for Victoria Climbié and in 2013, another child (known as Child T) was found to have suffered horrific abuse at the hands of his parents. Child T, at one time, was found to have in excess of 50 bruises on his body.

Baby Peter was born in 2006. Six months after moving in with his mother’s boyfriend, Steven Barker, a GP reported bruises on the baby’s face and chest. Barker was arrested and Baby Peter was placed in the care of a family friend for five weeks.

Baby Peter was then returned to his mother in January 2007. A month later, a whistleblower sent a letter to the Department of Health listing concerns about failings in child protection at Haringey Council.

In April 2007, Baby Peter was admitted to North Middlesex Hospital with two black eyes, swelling on the left side of his head and bruises. He was then re-admitted by a social worker who found 12 areas of injuries on Baby Peter’s body. Further injuries were missed by a social worker after they were deliberately hidden under chocolate.

The day after Baby Peter’s mother was told she wouldn’t face charges for child abuse on the 2 August 2007, Baby Peter was found dead in his cot.

Following Baby Peter’s death, his mother, Barker and Barker’s brother were found guilty of causing the baby’s death. Further repercussions included:

• Sharon Shoesmith, the director of children’s services at Haringey Council, who was in charge of Baby P’s care, was fired.
• GP Dr Jerome Ikwueke, who saw Baby Peter 14 times before his death, was suspended by the General Medical Council.
• Three managers and a social worker were fired for failings in the care of Baby Peter.
• The Care Quality Commission criticised the NHS for failing in its care for Baby Peter.

An independent report into the baby’s death was commissioned and a range of shortcomings were highlighted, which included:

• failure to identify children at immediate risk of harm and to act on evidence, including a failure to talk to children believed to be at risk
• agencies acting in isolation from one another without effective coordination
• poor gathering, recording and sharing of information
• insufficient supervision by senior management
• poor child protection plans
• failure to implement the recommendations of the Victoria Climbié inquiry

Having been asked to make recommendations for improvement for Haringey Council after Victoria Climbié’s death, Lord Laming was asked again to make recommendations on child protection. He recommended that:

• Directors of children’s services with no child protection experience should appoint an experienced social work manager to support them.
• The government should provide child protection training for council leaders and senior managers.
• The government should ensure social work students get more and better child protection training.
• Social workers’ employers should face disciplinary action over child protection failures.
• Court fees for applying to take children into care should be reviewed.
• Ofsted inspectors responsible for child protection must have direct experience of child protection work.
• The government should draw up explicit targets for the protection of children for all frontline services.

A national agency should be set up to oversee the swift and effective implementation of these recommendations.