Baby Peter case in Haringey

Haringey Council, criticised heavily over the death of Victoria Climbié in 2000, came under fire again over the death of 17-month-old baby Peter, 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 Connelly - 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.

Latest articles on baby Peter case

Trial

On  11 November, 2008, Peter's step-father, Steven Barker, and Barker's brother, Jason Owen, were convicted of causing or allowing his death. The baby's mother, Tracey Connelly, had already pleaded guilty to this charge.

Connelly and Barker were named in August 2009 after an order banning their identification, designed to protect Peter's four living siblings, was lifted.

During the trial, the court heard baby Peter 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, Barker was convicted of raping a two-year-old girl, who was also on Haringey's child protection register, though Connelly was cleared of cruelty towards the girl.

Later that month, Barker was jailed for life, with a minimum term of 12 years; Connelly was jailed indefinitely, with a minimum term of five years; and Owen was jailed indefinitely, with a minimum three-year term.

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:-

• Current practice in implementing safeguarding procedures, inter-agency working, ensuring effective public accountability and developing and deploying workforce capacity.
• Key barriers, including in the legal process, that may impede efficient and effective work with children and families.
• Specific actions that should be taken by government and national and local agencies to overcome these barriers.

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:-

• A failure to identify children at risk of immediate harm and to act on evidence.
• Agencies working in isolation from each other.
• Poor gathering, recording and sharing of information.
• Inconsistent quality of frontline practice and insufficient evidence of supervision.
• Insufficient oversight of the assistant director of children's services by the director of children's services and chief executive.
• Incomplete reporting of the management audit report by senior officials to elected members.
• Insufficient challenge by the local safeguarding children board to its members and also to frontline staff.
• An overdependence on performance data, which was not always accurate.
• Poor child protection plans.

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.

Shoesmith appeal following sacking

Later that month, the council sacked Shoesmith, without compensation and with immediate effect. 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 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. 

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.

On the request of Balls, Ofsted, the Care Quality Commission and the police inspectorate re-inspected Haringey six months after the JAR. Their findings, published in July 2009, were that Haringey had made only "limited progress" in safeguarding.

'Significant shortcomings'

They found "significant shortcomings" in staffing and the capability of some managers and social workers had held back progress.

One-third of posts in children's social care were filled by agency staff

Despite a "strong and shared" commitment to improving safeguarding across agencies, the inspectors found capacity to improve was "limited".

Reinspection 'too soon'

However, in a letter to Ed Balls, Ofsted chief inspector Christine Gilbert voiced concerns that Haringey had been reinspected too soon after the initial, damning JAR, and said some inspectors were reluctant to carry out the second probe.

In response, Balls accepted Gilbert's call for Haringey not to be inspected again until January 2010. In a letter to council leader Claire Kober, he confirmed that he would continue to expect monthly updates from Peter Lewis, but said any decision on further intervention would await the third inspection.

Staff dismissals and suspensions

In April 2009, Haringey Council announced the dismissal of four other employees in relation to the baby Peter case - Clive Preece, head of children in need and safeguarding services, and Cecilia Hitchen, deputy director of children's services, Maria Ward, Peter's allocated social worker and children's services team manager Gillie Christou.

The following month, it was revealed that Ward, Christou and Hitchen were all challenging their dismissals.

In December 2008, Christou and Ward were placed on interim suspension orders by a General Social Care Council committee, barring them from working as social workers.

In June 2009, these were extended, until December 2009 for Ward, and until March 2010 for Christou, pending a decision on whether a conduct hearing will be held into their cases. Should misconduct be proven it could lead to a life ban or a suspension from practice.

Other staff

The second inspection of Haringey, published in July 2009, revealed that a number of other staff had been suspended or dismissed in children's social care due to "poor practice and capability concerns".

This had followed the discovery of significant problems in the referral and assessment service by a taskforce, which had been commissioned by the council to clear a backlog of 400 unallocated cases, which had been identified earlier in 2009.

Serious case reviews

Ofsted had found that Haringey Safeguarding Children Board's original serious case review into baby Peter'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 Peter's injuries. Professionals placed a high degree of trust in Connelly because of her co-operation with them, which meant Peter's injuries were perceived to be largely accidental.

It said a paediatrician, who saw baby Peter 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 Peter died. By then, the individual management reviews to inform the SCR had been completed, meaning some important aspects were not adequately considered including:-

• The capacity of frontline services.
• The effectiveness of provision for other children in the family.
• The reasons why agencies failed to discover the two men living in the household - Baby P's stepfather and the lodger, Jason Owen.

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.

The SCR was finally published in May 2009. Unlike its predecessor, it concluded, unequivocally, that agencies should have saved Peter. Among its findings were that:-

• Care proceedings should have been initiated in December 2006, following a child protection conference, as the threshold was met.
• Agencies were too willing to believe Connelly's accounts.
• Too little significance was attached to her childhood experience of neglect and alleged abuse.
• Agencies failed to run checks on Barker.

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.Health

Health

Alongside Balls's statement on 1 December, 2008, then  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 Peter: 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 Care Quality Commission, which took over the Healthcare Commission's functions in April 2009, published the report on the four trusts in May 2009. This found that failings in the baby Peter case had not been fully rectified.

It found that issues that contributed to the failure to protect baby Peter, 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.

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.

Following the second JAR, published in July 2009, Fox told Community Care that staff felt they were "being very heavily examined on every case they deal with and the tiniest issues [are being] picked up".

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

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:-

• The establishment of new statutory targets for child protection.
• The creation of a National Safeguarding Delivery Unit, reporting to ministers, to oversee the delivery of Laming's recommendations.
• Reform of the social work degree to allow specialisation in children's social work after the first year.
• The General Social Care Council's code of practice for employers should be put on a statutory footing.
• The establishment of a conversion qualification for internationally qualified children's social workers that ensure understanding of practice, guidance and legislation in England.
• Directors of children's services who have no experience of child protection should appoint an experienced social work manager to support them.
• Government to ensure that budgets for child protection staffing and training are protected and that there is adequate funding for councils for early intervention and preventive work with children

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.

Impact of baby Peter case 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:-

• 54% agreed that children's social services were effective in protecting children, while 21% disagreed.
• 82% agreed children's social workers knew more about children's needs than politicians did. Nine per cent disagreed.
• 78% supported more resources for local council children's services, while 8% did not.

Impact 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 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

Baby P time line on Dipity.

November 2006 - Steven Barker, later found guilty of causing or allowing baby Peter's death, moves into her home but this is kept from police and social workers.
 
December 2006 - Tracey Connelly 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 Peter returned to his family after five weeks. 
 
April 2007 - Baby Peter 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 Peter'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 Peter 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 Peter case 

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

Blogs/opinion pieces

Baby P: The Sun

Baby P: Lost confidence

Baby P: Recruitment impact

Baby P: The media response

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