NHS failings in the Baby P case have not been fully rectified in the trusts concerned despite improvements since his death in August 2007, the Care Quality Commission said today.
A government-commissioned review found that issues that contributed to the failure to protect baby P, including poor communication between staff, under-staffing and the failure of health practitioners to attend child protection conferences, had not been fully overcome in the trusts concerned.
The review by the CQC’s predecessor, the Healthcare Commission, from January to March 2009, focused on services at North Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust and Great Ormond Street Hospital for Children NHS Trust (Gosh), which provides paediatric services on behalf of the other two bodies.
34 contacts with Baby P
Staff at the three trusts had 34 contacts with Baby P, excluding his birth. Today’s report found:-
- Poor communication between health staff, and between NHS and social services practitioners, had contributed to the failure to protect Baby P. For instance, concerns were not highlighted following Baby P’s visit to North Middlesex A&E in July 2007 – when he presented with bloody scabs on his scalp, among other injuries – because of a lack of knowledge about previous NHS contacts.
- The planning and review of Baby P’s care was not helped by health professionals’ failure to attend child protection conferences.
- Staff shortages at St Ann’s Hospital, part of Haringey PCT, contributed to Baby P waiting eight weeks for a paediatric assessment, which eventually took place on 1 August, two days before his death.
Poor child protection conference attendance
The review found that problems remained in all three of these areas. It found attendance at child protection conferences was “poor” among paediatric staff at North Middlesex and “below desired levels” among Haringey PCT paediatric staff. Both services are run by Gosh.
The report said doctors found it difficult to attend due to clinical commitments, while staff in both services said feedback from child protection conferences were inconsistent.
‘Serious concern’ over referrals
The review also identified a “serious concern” in the handling of child protection referrals to children’s services by North Middlesex paediatric staff.
It said some staff thought it was sufficient to fax a referral and not make a follow-up call, despite pan-London safeguarding procedures stating that a discussion between the social worker and the referrer was “essential”.
Health visitors and school nurses reported difficulties in making child protection referrals to children’s services, mainly because this happened at the end of the working day when council staff were difficult to contact.
The report also found that staff shortages were still a problem at Haringey PCT, with health visitors and school nurses facing excessive workloads.
Staff retention knocked by media coverage
It also said the media furore over the Baby P case had resulted in higher staff turnover “due to the pressure of working for a trust that is so much in the public eye”.
More positively, staff at the Gosh-run paediatric service at Haringey PCT said child protection awareness had “increased significantly” since Baby P’s death.
And overall, the review found the trusts had taken “robust actions” since failings in the Baby P case were identified, including in response to the first serious case review into his death, published in November 2008.
National child protection review
The CQC is due to publish a review of national child protection arrangements in the NHS – also commissioned by government in the light of the Baby P case – this summer.