The failure to protect Baby P was because of poor practice by health professionals, social workers, police and lawyers rather than systematic breakdown, a serious case review found.
Professionals in the London borough of Haringey saw the boy 60 times before his death, caused by his mother and stepfather, and the inquiry found agencies communicated with each other and procedures were largely followed.
However, there was a poor flow of information in some areas. Despite being on the child protection register for the final eight months of his life, there was a “pervasive belief” that the 17-month-old boy’s injuries were accidental.
Professionals believed mother
Few professionals challenged the mother’s account that these were the result of an “active” child who often bumped into and head-butted things, and only considered that she was guilty of poor supervision.
Sharon Shoesmith, chair of Haringey local safeguarding children board and director of Haringey children’s services, said: “The mother seemed to be co-operating with us: taking the child to the doctor’s when he was ill, seeking help.”
Flawed paediatric assessment
However, only one mistake was highlighted as “critical” in the failure to identify the abuse. This was made by the paediatrician who examined the boy 48 hours before he died.
By this stage the child had suffered serious injuries, including fractures to his ribs and spine, but the paediatrician’s assessment recorded that he was “miserable” with a viral infection.
The review found that expert medical opinion “concluded that a diagnosis of abuse should have been made at that point”.
Care threshold ‘not met’
A week before the boy died, social workers were advised by Haringey Council’s lawyers that the threshold for launching care proceedings had not been met.
The risk was compounded by the presence of the boy’s stepfather, who lived in the house for up to six months without the knowledge of the child protection team.
The report made 45 recommendations aimed at agencies covering six professional areas. These included inviting paediatricians to child protection conferences, and training for managers supervising professionals involved in safeguarding work, ensuring they were “vigilant” and “open and inquisitive”.
Yesterday the stepfather, 32, and a lodger, Jason Owen, 36, were convicted at the Old Bailey of causing of allowing Baby P’s death in August last year. His mother, 27, had already pleaded guilty to the same charge.
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