Haringey Council, criticised heavily over the death of Victoria Climbié in 2000, came under fire again over the death of 17-month-old Baby P, in August 2007.
The case, like Victoria's, triggered national outrage and widespread reforms to the child protection system in England.
The boy - later named as Peter - was on Haringey Council's child protection register throughout eight months of abuse in which he suffered more than 50 injuries.
His family had been seen 60 times by agencies including social workers from the council, which previously found itself at the centre of a national outcry over the murder of Victoria Climbié by her great-aunt and her boyfriend.
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Trial
On 11 November, 2008, two people were convicted of causing or allowing the death of the 17-month-old Baby P, including his step-father. The baby's mother had already pleaded guilty to this charge.
During the trial, the court heard Baby P was used as a "punchbag" but his mother manipulated professionals with lies and smeared him with chocolate to hide his bruises. The boy was found dead in his blood-spattered cot 48 hours after a doctor failed to spot his broken spine.
In May 2009, Baby Peter's step-father was convicted of raping a two-year-old girl, who was also on Haringey's child protection register, though Baby P's mother was cleared of cruelty towards the girl.
Aftermath
The trial led to concerted government action to address a widespread loss of confidence in the child protection system, both in Haringey and more widely.
Ministers announced a national child protection review, headed by Lord Laming, who led the inquiry into the death of Victoria Climbié. This would cover:-
Children's secretary Ed Balls also said it would incorporate previously announced reviews of serious case reviews and local safeguarding children boards.
Joint area review
Balls also ordered Ofsted, the Healthcare Commission and the police inspectorate to conduct an urgent joint area review (JAR) of safeguarding in Haringey, and report by 1 December.
He also brought in John Coughlan, Hampshire Council's director of children's services, to provide support to Haringey's senior management in children's services, including children's director Sharon Shoesmith.
Devastating
On 1 December 2008, Balls received the JAR as well as an initial report from Laming on his findings, and on the same day announced his response in a public statement.
He said the JAR had revealed a catalogue of safeguarding failings in Haringey including:-
Haringey overhauled
The leadership of Haringey Council was overhauled. Before his statement, council leader George Meehan and cabinet member for children and young people Liz Santry resigned.
But Balls then announced that he had used powers under the Education Act 1996 to direct Haringey to remove Sharon Shoesmith from her post as director of children's services and appoint Coughlan to replace her throughout December 2008.
Later that month, the council sacked Shoesmith, without compensation and with immediate effect.
Shoesmith appeal
In March 2009, Shoesmith lodged a claim for unfair dismissal against Haringey Council. She also launched separate judicial review challenges against the role of Ofsted, Haringey Council and Balls in her dismissal.
Balls then directed Haringey to appoint Peter Lewis as its new director of children's services, with effect from 1 January 2009. He also said he had asked Lewis to provide him with a monthly update on his progress in turning around Haringey.
Ofsted is due review progress on the JAR and report back to Balls by June 2009. He wwill then decide whether further sanction was needed - including requiring the council to outsource some or all of its children's services responsibilities to an external provider.
Other staff
In April 2009, Haringey Council announced the dismissal of four other employees in relation to the case - Clive Preece, head of children in need and safeguarding services, and Cecilia Hitchen, deputy director of children's services, Maria Ward, Baby P's allocated social worker and children's services team manager Gillie Christou.
The announcement came with Christou and Ward under interim suspension orders, imposed by the General Social Care Council, barring them from working with children.
The workforce regulator is considering whether to hold a conduct hearing into their cases, which could lead to a life ban or suspension from working as a social worker, should misconduct be proven. It could also lead to the first conduct hearing involving more than one social worker.
New LSCB chair appointed
Balls also directed the appointment of a new and independent chair of the LSCB to replace Shoesmith, in the person of Graham Badman, former director of children's services at Kent Council.
Ofsted had found that the LSCB's original serious case review into Baby P's death, which reported on 12 November, 2008, was inadequate.
This found that agencies had failed to develop an adequate understanding of the reasons for Baby P's injuries. Professionals placed a high degree of trust in Baby P's mother because of her co-operation with them, which meant Baby P's injuries were perceived to be largely accidental.
It said a paediatrician, who saw Baby P two days before he died, when he was believed to already have a broken back and ribs, should have made a finding of abuse.
Critique of SCR
However, Ofsted found the SCR had terms of reference that were insufficiently comprehensive, lacked clarity and were not finalised until 12 December 2007, four months after Baby P died. By then, the individual management reviews to inform the SCR had been completed, meaning some important aspects were not adequately considered including:-
It also found the SCR panel was insufficiently independent, being chaired by Sharon Shoesmith.
Second SCR
Ball ordered a new SCR, under the new LSCB chair, which he said should report by the end of February, 2009. Its executive summary should be published by the end of March and should provide a "comprehensive and fair summary" of the review, Balls added.
The March target was not met, however, as publication of the second SCR was delayed by the trial which led to the conviction of Baby Peter's step-father for the rape of the two-year-old girl.
In a statement on 1 May, 2009, Badman said he hoped to publish the SCR, which had been completed, as soon as was "legally permissable". But he revealed that it had found:-
SCR reforms
Also on 1 December, 2008, Ofsted published a report on SCRs in 2007-8, which found that 20 out of 50 had been inadequate.
In his statement on the same day, Balls said that each LSCB with an SCR judged to be inadequate should have the review reconsidered by an independent person. He said the same process would be used for any future inadequate SCRs.
Laming
On 12 March 2009, Laming delivered his review on child protection, which called for an overhaul of social work training and management.
Key recommendations included:-
Balls said the government accepted all of the recommendations. In May 2009, it produced its full response to his review, which included details on how the National Safeguarding Delivery Unit would be taken forward alongside a £58m programme to invest in workforce development for children's social workers.
Though it responded to all of Laming's recommendations, actions on many of them were deferred pending a review of the Working Together to Safeguard Children guidance, due to be issued by December 2009, and the final report of the Social Work Task Force in October 2009.
Health
Alongside Balls's statement on 1 December, 2008, health secretary Alan Johnson made a statement on the implications of the Baby P JAR for the health service.
He said: "The report highlights clear failures by the local NHS organisations to communicate properly and share information and expertise. These failures are unacceptable."
Johnson said he had asked the Healthcare Commission to urgently review whether NHS bodies were applying national child protection standards "as vigorously as they should be".
He said the commission had also agreed to report on the role of the four local NHS trusts involved in the events leading up to the death of Baby P.
The trusts are North Middlesex University Hospital NHS Trust, the Whittington Hospital NHS Trust, Haringey Teaching Primary Care Trust, and Great Ormond Street Hospital for Children NHS Trust.
The commission said the review would focus on:-
Johnson also said that NHS chief executive David Nicholson had written to all NHS bodies asking them to review their child protection arrangements and ensure staff are adequately trained.
Social workers' reaction
A Community Care survey of 250 readers in the wake of the case found eight out of ten believed the government should bring in new management at Haringey.
However, readers also warned against a rush to judgement over individual failings in the case, while over 40% felt media coverage of the case was affecting their practice and could adversely affect recruitment into the profession.
Morale at Haringey
Community Care also learned that morale had sunk at Haringey among children's social workers. Local Unison branch secretary Sean Fox said professionals were being subjected to verbal abuse by clients, egged on by "disgraceful" coverage in the tabloid press.
Haringey's response
In February 2009, Haringey Council published an action plan to transform provision of safeguarding. The council - rated as inadequate for children's services by Ofsted in 2008 - set a target of being satisfactory by 2009 and outstanding by 2012.
The plan included a 'core offer' for frontline staff by August including high quality supervision, "reflective" practice, balanced workloads and investment in office accommodation and IT systems. The plan also pledged more support staff in order to free up social workers to spend the "maximum" amount of time with children and families.
Other measures included driving up recruitment of permanent staff and reducing the number of agency workers and improving leadership and partnership working
Impact of Baby P on standing of social workers
A number of opinion polls following the trial measured the impact of the case on social workers' standing with the public.
A Local Government Association poll in March 2009 found four out of ten people had a worse opinion of social workers in the light of the case. However, other results proved more encouraging, for instance:-
Impact of Baby P on recruitment
A Local Government Association survey published in December 2008 but conducted before news of Baby P broke found nearly two-thirds of social workers were struggling to recruit children's social workers, and the LGA warned the situation could worsen in the light of the case.
This was borne out by research published by the LGA in May 2009. A survey of 56 councillors in charge of children's services found 57% had found it more difficult to recruit children's social workers in the previous six months.
The concerns sparked a series of initiatives from the LGA and DCSF to address the problem, notably the launch of a campaign to encourage thousands of retired or former children's social workers to return to the profession.
In its response to the Laming report, the DCSF said a helpline would be up and running by July 2009 to support returners while refresher training for the group would be rolled out from 2009-10.
Impact of Baby on care proceedings
The case also seemingly had a telling effect on the number of applications for care orders by councils.
In May 2009, family court body Cafcass reported that the number of applications from November 2008 to March 2009 was one-third up on the same period in 2007-8, with record levels in March 2009.
Cafcass said this could mean that councils had lowered their thresholds for care orders in the aftermath of Baby P, though other children's services leaders were sceptical over whether this would be a long-term trend.
Timeline of case
November 2006 - Mother's boyfriend, later found guilty of causing or allowing Baby P's death, moves into her home but this is kept from police and social workers.
December 2006 - Mother arrested after bruises spotted on baby's face and chest by a GP. She denies causing injury. He is admitted hospital, placed on the child protection register, then handed to a family friend.
January 2007 - Baby P returned to his family after five weeks.
April 2007 - Baby P admitted to hospital with bruises, two black eyes and swelling on the left side of his head. The mother claimed it was from a fall on to a marble fireplace caused by another child. The episode is not reported to police.
June 2007 - Marks seen on Baby P's face by social worker. She sends him to hospital where bruises and scratches are found. The mother is re-arrested. Arrangements are made to pay family friend to live at the house for two weeks and then for a childminder to take the boy in the daytime.
July 30 2007 - Social worker misses injuries to the boy's face and hands after he is deliberately smeared with chocolate to hide them.
August 1 2007 - Baby P is taken to a child development clinic. Doctor misses his broken back and ribs despite the child crying in pain.
August 2: 2007 - The mother is called to the social services office and told by police she would not be prosecuted following consideration by the Crown Prosecution Service.
August 3 2007 - The boy is found dead in his cot.
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More information
Haringey Council statement and serious case review
Articles on Baby P
Serious case review rules out systematic breakdown
Baby P case prompts government to commission second Laming review
Victoria Climbié Foundation demands public inquiry into Haringey abuse case
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Details of government consultations
12 June 2009
Government Legislation
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Private Member Bills
21 November 2008
