In 16 pages, the errors that cost the life of a 17-month-old

A devastating picture of child protection failings in Haringey has been revealed by the report of an inspection team sent into the authority after Baby P's death.

The 16-page document details failures of council management and frontline services that raise "serious concerns" about the council's ability to safeguard children.

Inspectors from the Office for Standards in Education, the Healthcare Commission and HM Inspectorate of Constabulary found the work of local services to improve outcomes for children at risk was "inadequate and needs urgent and sustained attention". They criticised cross-agency co-operation, management, record keeping and risk assessment.

Management

Local politicians and senior council officials provided "inadequate" leadership and management of children's services and "the quality of frontline practice across all agencies is inconsistent and not effectively monitored".

There was a "managerial failure" to meet the demands of the inquiry into the murder of Victoria Climbié in 2000 and "insufficient evidence of managerial oversight and decision-making on case records" in children's and health services and the police. Evidence of plans being "robustly put into practice on the ground" was limited.

The Baby P review

Inspectors condemned as inadequate the serious case review carried out after the death of Baby P and said the panel that carried it out was insufficiently independent. The council's now-suspended head of children's services, Sharon Shoesmith, chaired the panel.

Nine agencies involved in the case produced reports that formed part of the case review, but five were judged to be inadequate, including those by children's social care services and the Haringey Teaching Primary Care trust, which "lack rigour" and thus undermined the review's integrity.

The review was attacked for failing to address the effectiveness of frontline services, the help offered to "other children in the family", and the reasons why agencies failed to discover the two men living in the household. The review "misses important opportunities to ensure lessons are learnt".

Risk assessment, record keeping and planning

Risk assessments failed to identify children in most danger, inspectors found. They warned that children are put at risk by the "repeated failure" to take account of past concerns about their welfare. Information from different agencies was not always taken into account and there was "weak analysis and understanding of the risks" to the child. Managers in all