Report reveals damning failings in Baby P case

More damning failings that led to Baby P's death will be revealed today with the publication of previously secret official reports.

The toddler died due to the incompetence of "almost all the staff in every agency involved", according to details from two serious case reviews reported today.

Baby P's GP failed to report suspicious bruises, police failed to fully investigate his injuries and a key meeting between lawyers and social workers to decide whether he should be put into care was delayed for seven weeks, The Sun said.

So far only summaries of the two "serious case reviews" carried out into the tragedy have been released.

Now the documents are being made public in full, following pledges by Conservative and Liberal Democrat politicians.

Baby P, now named as Peter Connelly, was just 17 months old when he died in Tottenham, north London, at the hands of his mother, Tracey Connelly, her boyfriend Steven Barker and his brother Jason Owen in August 2007.

He suffered more than 50 injuries despite receiving 60 visits from social workers, doctors and police over an eight-month period.

The first serious case review, published in November 2008, was overseen by Sharon Shoesmith, who was later sacked as director of children's services at Haringey Council in north London over failings exposed by Peter's death.

It found "numerous examples of good practice" in the toddler's care, although it also noted some weaknesses in information flow.

But Ofsted inspectors ruled that this report was inadequate and former children's secretary Ed Balls commissioned a fresh investigation.

The second serious case review was released in May last year to coincide with the sentencing of the trio responsible for Peter's death.

It was far more critical, finding that the tragedy "could and should have been prevented", but social workers and other agencies were too concerned with keeping mother and child together.

Social workers, doctors, lawyers and police should have been able to stop the situation "in its tracks" at the first serious incident but their practice was "completely inadequate", it said.

The review concluded: "Peter deserved better from the services which were there to protect him, and they in turn deserved better than the ethos which influenced their work at the time."

The full reports will be released today at a press conference at Haringey Civic Centre in Wood Green, north London.

The event will be attended by Children's Minister Tim Loughton, Haringey director of children's services Peter Lewis, and Graham Badman, who chaired the second Baby P report.

Ministers have also pledged to release the full serious case reviews for Shannon Matthews, who was kidnapped by her own mother in February 2008, and the two young brothers who tortured two other boys in Edlington, South Yorkshire, in April 2009.

The full report into the case of Khyra Ishaq, who died in Birmingham in May 2008 after months of starvation and cruelty at the hands of her mother and stepfather, was published in July.

Serious case reviews are carried out after a child dies or is seriously injured through abuse or neglect to see what lessons can be learned.

But until now the detailed findings of the reports have been kept confidential and only a summary has been published.

The previous Labour government said publishing them in full would put vulnerable children and their families at greater risk, as well as making people more reluctant to take part in child abuse investigations.

The second report highlighted child protection officials' failure to establish Barker's identity, interview him and carry out background checks on him.

Connelly told social workers he was only a friend and was not left alone with Peter.

But Barker apparently accompanied her to hospital in April 2007 after the toddler suffered a head injury, and he was present when a family support worker visited Connelly at home two months later.

The report noted: "Hovering in the background to the situation is Mr H (Barker), the male friend of Ms A (Connelly).

"The nature of his relationship to Ms A is not known, the extent of his involvement with the household is also not known, and most importantly his possible criminal background, anti-social behaviour or general background, is not known.

"A man joining a single parent household who is unrelated to the children is well established in research as a potentially serious threat to the well-being of the children.

"He needs to be checked out and his involvement with and relationship to the children carefully assessed."

Mr Loughton said there was a "certain complacency" to the first serious case review overseen by Ms Shoesmith.

He went on: "I think it was insufficiently thorough and insufficiently critical at trying to find out the underlying problems and the way that certain agencies did not interact with each other."

Graham Badman, who chaired the second serious case review, said the panel he worked with was of "a completely different level of seniority".

Speaking at a press conference at Haringey Civic Centre in Wood Green, north London, he described how none of the agencies involved with Peter checked Barker's background.

"It's a major issue. There are several occasions where we say the insertion of an unidentified man into a vulnerable family may be benign or it may be dangerous," he said.

"There were times where there should have been far greater questioning of the relationship between Tracey Connelly and the boyfriend."

Mr Badman added: "We make it very clear that Peter's death could have and should have been avoided.

"There have been significant changes to the way in which Haringey services are conducted.

"If Peter Connelly is to have any legacy at all, it is that children are now safer."

Mr Loughton said: "This isn't about a blame game, it's about tying to achieve some degree of closure.

"This has been in the headlines for most of the last two years.

"I think it will be in everybody's interests, for the family tragically involved and for the professionals involved in this borough and beyond, if we can learn these lessons, achieve some degree of closure and move on."

Downing Street described the report as "shocking".

David Cameron's spokesman said the Prime Minister had been briefed on it, adding: "It's clearly a shocking report."

Lynne Featherstone, the Liberal Democrat MP for Hornsey and Wood Green in north London, welcomed the publication of the full reports.

She said: "Public confidence can only be restored after the full story behind the tragic failings that led to Baby Peter's death is known."









The NSPCC said it hoped lessons would be learned from the reviews of Peter's case.

A spokesman for the children's charity said: "If we are to protect vulnerable and defenceless children we have to have first class, properly resourced children's services. Anything less increases the risk of more young victims dying unnecessarily.



"Many opportunities to help Baby Peter were missed and although professionals on the frontline are often under huge pressure they must have the skill, experience and courage to make the correct decisions.



"The child must always be the focus of attention, not the parents, which sometimes happens with dreadful consequences. And if children need to be protected swift action will sometimes be necessary."















Other key findings of the second serious case review include:

* Haringey Council's expectations of parents in the borough appeared to be "too low", meaning many children could be experiencing "unacceptable levels of neglect and emotional deprivation";

* When Peter was taken to hospital with suspicious bruises and swelling on his head in December 2006, it would have been "reasonable" for Haringey social workers to infer that an adult had inflicted the injuries and that others were covering up the person responsible;

* Connelly was a "dominating and forceful personality" who intimidated the staff involved in the case. They were too willing to believe her explanations for Peter's injuries;

* Peter was regarded by child protection officials as a "routine case" with his injuries occurring "as a matter of course";

* When Connelly took the toddler to hospital with new serious injuries in April 2007, officials should have placed him in temporary foster care. The report noted: "There seems little point in making a child the subject of a child protection plan if the parental care of the child continues unchallenged, and the child continues to be subject to the same harm which precipitated the need for the plan in the first place";

* At no point did it occur to the authorities that Peter's injuries were caused by someone other than his mother;

* There was an "unacceptable" delay of seven weeks to arrange a legal meeting to discuss whether Peter could be taken into care;

* When the meeting did take place, on July 25 2007, the lawyer was "relatively inexperienced" and did not have a medical report about the little boy's injuries. The lawyer incorrectly judged that the threshold for Peter to be taken into care had not been reached.

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