There was nothing in the circumstances of Baby P's birth on 1 March 2006, at the North Middlesex Hospital in Edmonton, north London, to suggest his life was destined to be brutal and tragically short.
The North Mid, as it is known, had long since cast off its workhouse origins. Its children's facilities, run as they are by specialists from the world renowned Great Ormond Street Hospital, are first rate. He was born, at least, in good hands.
His mother, just short of her 25th birthday, and his father had finally been blessed with a much-wanted son after three daughters. Their family appeared complete.
This little joy was short-lived. The couple's relationship was already on the rocks. Baby P's mother was 16 when she met his father, who at 33 was twice her age. The couple had two daughters before they married in September 2003. They had another girl before Baby P became their fourth child.
Three-and-a-half months after he was born, his father quit the family home, citing his wife's infidelity. One of the men she was accused of sleeping with moved in four months later. Friends of Baby P's mother said the new relationship appeared to be good for her, that she seemed happy and settled for the first time in a while. Online, she boasted how great it was to be "in love".
Until October 2006, none of the professionals involved with Baby P, his GP or health visitor, had reason to be concerned for his wellbeing. His mother attended clinics and regularly took him to see his GP, Dr Jerome Ikwueke. Baby P had had his jabs and his development seemed normal. They were more concerned about his mother, who had been treated for depression before her husband had left.
All that changed on Friday 13 October when Dr Ikwueke saw bruising on the side of the infant's head and chest. The mother told him that Baby P had fallen down the stairs. Almost one month later when Dr Ikwueke examined him again Baby P had a bulging 2in bruise in the middle of his forehead as well as bruising on his chest and right shoulder. Concerned by his mother's unclear explanation for the injuries – she suggested they might have occurred while he was being cared for by his grandmother – the GP referred mother and child to a specialist at the Whittington Hospital in north London.
Dr Heather Mackinnon, the specialist who examined him the following day, was so disturbed by his condition she referred him to Haringey social services. Baby P was taken into temporary care and police were called in to investigate. His sisters were also examined but showed no injuries.
Haringey social services put P into the care of a registered childminder who was also an old friend of Baby P's mother while it investigated. The woman who looked after him for six weeks over Christmas 2006 noted that he did not get any more bruises and ate and slept well. However, she reported that he would head-butt, scratch and bite. His mother continued to have extensive access to him. During this period social workers visited seven times in two weeks, including an unannounced visit to check on him.
At the end of six weeks, despite the continuing police investigation and numerous visits, they remained unaware that the mother's boyfriend was living in the house.
They didn't know that when Baby P's family moved to a new home in Tottenham in January 2007, his mother's boyfriend moved in a short time later. It wasn't a total secret: a friend of Baby P's mother later told police she saw him regularly at the property. Disturbingly, she also told them she had noticed blood coming out of Baby P's ear on two occasions after the boyfriend had bathed him. Another relative who stayed temporarily at the house described to detectives how most of the housework and childcare was done by the boyfriend while the mother spent her time on the sofa smoking and complaining of fatigue or visiting computer chatrooms.
Professionals continued to monitor the family regularly, sometimes two or three times a week. Court evidence later revealed that the longest period the children went without contact with at least one professional was 10 days. The court also heard that social services only made two unannounced visits between January 2007 and Baby P's death eight months later.
During that period Dr Ikwueke again noticed bruising on the baby's face and despite the mother's explanation that he had been pushed into a fireplace by another child, he referred the infant to a senior doctor at the North Middlesex. That doctor described how, when he examined him, the 13-month-old child was holding his head to one side and was unsteady on his feet. He was admitted to hospital overnight but released the next day.
Social workers continued to visit. A subsequent inquiry said they believed P was an "active child", who was seen to throw his body around and head-butt family members and other objects. "These appeared to support the mother's concerns that her son suffered frequent accidents due to being an active, clumsy child with a high pain threshold."
They concentrated on discovering if there were "organic reasons for such behaviour". The mother's two elder daughters did not give cause for concern. Despite questions of lack of hygiene and unkemptness, both attended school regularly. Sources close to Haringey council later told lawyers their main concern was one of neglect and poor parenting skills rather than abuse. They remained unaware of the boyfriend's presence in the house. On one of only two occasions when social workers turned up without invitation, they discovered more bruising and scratching on P. He was immediately examined by a senior doctor at the North Middlesex Hospital who found multiple bruises.
Four days later his mother was interviewed under caution at Hornsey police station. Detectives visited the house to photograph P's injuries and the furniture he was said to have collided with. Social workers placed the eldest daughter on the child protection register while Baby P and his youngest sister were looked after by a childminder for 10 days while the investigation proceeded.
Somehow, the boyfriend's presence in Baby P's home remained undetected throughout this investigation. It wasn't until 15 June that Marie Lockhart, a Haringey family support worker, was introduced to a tall blond man whom Baby P's mother described as a "friend". It was the first time that anyone in authority appeared to learn of his existence.
More astonishing, perhaps, is the fact that not only did the boyfriend's presence in the home remain unknown for so long but so did that of Jason Owen. At some point in early June, Owen, 35, had arrived at the house with his 15-year-old girlfriend and five children, aged variously from seven to 14, together with a pet snake. At some point he also added a Rottweiler dog. Police were later told he was "hiding" from people,
Baby P's mother later claimed she had asked Owen and the others to leave but they had refused. A friend said the mother was unhappy with the situation and "frightened of Owen". Despite this, she did not mention her fears to anyone in authority.
In what would prove the last months of his life, Baby P's general condition deteriorated. A childminder noted he had become lethargic and spent more time in his playpen but didn't want to play. His hair had been shaved in a radical attempt to curb head lice and he had extensive infections on his scalp, ears, fingers and toes. His mother continued to take him to a variety of doctors who prescribed antibiotics.
On 25 July Haringey's Children and Young Persons Service presented all the evidence it had collated to the council's legal department. Lawyers told the social workers that "on the basis of the information provided, the threshold for initiating care proceedings ... was not met."
The same month police finished their enquiries into the injuries P sustained in December 2006 and June 2007. Detectives said their efforts had proved inconclusive and no criminal charges would be brought.
In late July, P spent an evening with his father. He presented a sorry sight with his infected head and a bandaged left hand. His mother said P had pulled his nail off. His father returned his son the following morning. It would be the last time he was to see him alive.
On Wednesday 1 August, his mother and the childminder took Baby P to the Child Development Centre at St Ann's Hospital where they saw consultant paediatrician Dr Sabah Al-Zayyat. She examined him and found bruises on his face and around his shoulder blades. She prescribed antibiotics and referred him for more tests at Great Ormond Street and North Middlesex hospitals. She also advised the mother to keep an appointment with P's GP the next day.
The mother did not keep that appointment. Instead she called Marie Lockhart, the family support worker and said she didn't want to see anyone for a "couple of weeks". The Haringey worker agreed to contact her at the end of August.
On the morning of Friday 3 August the London Ambulance Service received a 999 call. Paramedics called to Baby P's house described how they found P's mother on all fours crouched over a child who was blue and wearing only a nappy. When they picked him up he was stiff and showed no signs of life. Resuscitation began immediately. After collecting her cigarettes, P's mother joined them for the journey back to the North Middlesex Hospital where his short, pain-filled life had begun. At 12.20, despite the best efforts of the medical team, Baby P was pronounced dead.
Asked whether her child had been unwell his mother replied: "Yes, he was unwell last night but I didn't bring him to hospital because I get accused of hurting him." After being told P was dead she was heard to cry: "Oh God, don't take away my baby boy; I have been waiting so long for a boy."
When the infant's father turned up, onlookers said she appeared "shocked" and kept repeating, "I'm sorry, I'm sorry." Baby P's mother was arrested for murder shortly afterwards and taken to Edmonton police station. When police visited P's home they finally met her boyfriend, who told them he was a friend who had been "visiting" that morning. He claimed he knew P's mother from doing "maintenance work". After he was arrested, he admitted he had known her for more than two years but insisted they were "just good friends". Only after a final interview did he admit that they had a sexual relationship and that she was three months pregnant with his child.
While being interviewed the two men made allegations about each other's involvement in P's death. Owen claimed P's mother and her boyfriend had, prior to P's death, "wrapped him up like a cocoon and laid him face down on the floor and left him there all day". The boyfriend claimed Owen had gathered the bedding from P's cot into a black dustbin liner and disposed of it.
Detectives admit that the absence of forensic evidence and the lack of reliable evidence from those involved in P's last moments meant that they would always have struggled to convict anyone of murder. After deliberation, the Old Bailey judge directed the jury to acquit the three defendants of murder. They were found guilty of an alternative charge of causing or allowing his death. In a bitter irony, this was one of the few decisive acts by anyone in authority dealing with the 17 chaotic months of Baby P's life.
A time for answers
Despite a trial and numbers of "reviews" of the tragedy, there are many unanswered questions to do with the killing of the 17-month-old known as Baby P. For legal reasons, we can see his face and blond hair, but his name remains as obscure as many of the details of how he came to die. Here are some of those questions:
What we know
Baby p was seen by his social worker four days before he died, but she found nothing to concern her. The consultant paediatrician who saw him in A&E two days before he died failed to notice a broken back and eight broken ribs; she fell short of expected standards and could face a "fitness to practise" hearing at the General Medical Council.
Dr Heather Mackinnon, paediatric consultant in charge of Baby P's care at the Whittington, said she failed to receive any minutes from the case conference meetings in which the decision to return him to his mother's house was made against her advice. Two separate police investigations were launched after suspected non-accidental injuries were found by doctors. No charges were brought against anyone.
The Government's performance targets for the number of social work assessments had been met by Haringey.
What we don't know
What were the quality of these assessments by social workers and who carried them out?
Why was it Sharon Shoesmith – Haringey's director of children's services – and not an independent expert who chaired the serious-case review into the handling of Baby P?
Why did Baby P's General Practicioner send him to A&E with his mother when he had concerns about his injuries and why did he not insist on a full child-protection medical examination?
What efforts were made to check the mother's claims that Baby P was clumsy and that he was responsible for the scratches, bruises and other visible injuries?
Why were so few unannounced and out-of-hours visits made by the social work team when there were concerns about abuse?
What we need to know
How did social workers and other professionals fail to notice that there were seven other people living in the house with Baby P and his mother, including four children under the age of 16, as well as a Rottweiler?
How did the social worker's manager, Gillie Christou, come to be under the impression that Baby P was being supervised 24 hours a day by a family friend, when actually that friend rarely spent the night in the same house?
How many times did Ms Christou meet Baby P and his mother?
On what grounds did the legal team decide that the evidence in Baby P's case was below the threshold to initiate care proceedings in court? And why did the social worker and her manager not insist, if they felt Baby P was at risk of further harm?
How much contact did Baby P have with his biological father after his relationship ended with the mother? And did the biological father ever contact social services to discuss his son
The key players
NevRes Kamal is a former social worker who wrote to the Government and social service inspectors six months before Baby P died to warn them about inadequacies in the way that Haringey borough council dealt with child abuse.
Maria Ward was appointed as the social worker responsible for Baby P's case in February 2007. She made at least nine visits to his home. She last saw him four days before he died, and was content with the protection plan in place.
Social work manager
Gillie Christou, as Ms Ward's senior, was responsible for supervising her work and approving decisions about the level of support that Baby P was getting.
Dr Sabah al-Zayyat was the last doctor to see Baby P alive. He was presented to her just two days before he died. She failed to notice his broken back and ribs and is now banned from working with children unsupervised. She may yet face a GMC hearing.
Dr Heather Mackinnon referred Baby P to social services after she found evidence of non-accidental injuries in December 2006. She recommended that the child should not be sent home with his mother and was never told this had happened.
Paulette Thomas only saw the baby four times in six months because the mother cancelled four appointments. Ms Thomas reported no concerns at his one-year development check.
Director of Haringey borough's Children's Services
Sharon Shoesmith chaired the council's "independent" serious case review and blamed legal advice for the decision not to go to court. She decided that no one, including herself, should lose their job over the death.
Met's child abuse investigation head
Caroline Bates will be asked to explain why two investigations into suspected child abuse were dropped with no charges. Police told Baby P's mother that there would be "no further action" the day before he died.
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