The full statement made by Ed Balls in response to the joint area review in Haringey is reproduced below.
The whole nation has been shocked and moved by the tragic and horrific death of Baby P. All of us find it impossible to comprehend how adults could commit such terrible acts of evil against this little boy. And the public is angry that nobody stepped in to prevent this tragedy from happening.
I want to say very clearly at the outset: social workers, police officers, GPs, health professionals, all the people who work to keep children safe, do a very difficult job, often in really challenging circumstances – all around the country and in particular in Haringey. They make difficult judgements every day that help to keep children safe – and many of them are unsung heroes. But they must also be accountable for their decisions.
And where things go badly wrong, people are right to want to know why and what will be done about it. In the case of Baby P, things did go tragically wrong.
I received the full confidential Serious Case Review into the death of Baby P on the morning of 12 November. After studying it and seeing the clear failings of practice and management that it highlighted, I immediately arranged for the secondment to Haringey of John Coughlan, the Director of Children’s Services in Hampshire, to oversee that proper procedures for safeguarding children are in place and being followed.
We also immediately decided that Ofsted, the Healthcare Commission and the Chief Inspector of Constabulary should carry out an urgent inspection of safeguarding in Haringey.
At 6 o’clock yesterday evening, I received the final draft of the inspectors’ report. The Children’s Minister and I studied it overnight with our experts. Her Majesty’s Chief Inspector Christine Gilbert presented the final report to us at 9 o’clock this morning and to Haringey Council shortly thereafter. And copies of the final report and my response have been passed to the Home Secretary, the Health Secretary, the Opposition spokespeople, the two local MPs and the Chairman of the Select Committee.
This morning, I met with the Leader, Deputy Leader, Lead Member for Children’s Services and Chief Executive of Haringey Council to discuss the report’s findings and my response. I am grateful for Haringey’s co-operation and agreement to act upon my decisions. And as you will know, in the last hour, the Leader of the Council and the Lead Member for Children’s Services have announced their resignations.
Over the past fortnight, as part of their work, the Inspectors have studied the case files on Baby P and his family, the full Serious Case Review and a significant number of other child protection case files – and their report delivers a damning verdict on the current management of safeguarding in Haringey.
In their summary judgement, the Inspectors say that there are:
“…a number of serious concerns in relation to safeguarding of children and young people in Haringey. The contribution of local services to improving outcomes for children and young people at risk or requiring safeguarding is inadequate and needs urgent and sustained attention.”
They find that:
“…the arrangements for the leadership and management of safeguarding by the local authority and partner agencies are inadequate.”
The catalogue of failings reported to me – many of which are clearly apparent in the case of Baby P – include:
– a failure to identify those children and young people at immediate risk of harm and to act on evidence;
– agencies generally working in isolation from one another and without any effective co-ordination;
– poor gathering, recording and sharing of information;
– inconsistent quality of front-line practice and insufficient evidence of supervision by senior management;
– insufficient management 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 front-line staff;
– an overdependence on performance data, which was not always accurate;
– and poor child protection plans.
The Inspectors also highlight a failure to talk directly to children at risk; and where children were not seen alone, it worries me greatly that the Inspectors find little evidence of management follow-up to ensure that children suspected of being abused were properly heard and able to speak up without fear.
Furthermore, in the particular case of Baby P, Ofsted has judged the Serious Case Review into his death to be inadequate.
Having studied the nine individual agency management reports on which the Serious Case Review is based, the inspectors judged:
– only three to be good;
– one to be adequate;
– and five to be inadequate – with the reports from Haringey children’s social care services and the Haringey Teaching Primary Care Trust judged to “lack rigour in their analysis and thus significantly undermine the integrity of the serious case review.”
And they conclude that:
“As a result, the serious case review misses important opportunities to ensure lessons are learned.”
Overall, the Inspectors’ findings are – I have to say – devastating.
Their report sets out detailed recommendations, all of which must now be accepted in full. And having studied their report, I have decided to take immediate action.
My first priority is to put in place a new leadership and management team in Haringey children’s services to ensure that vulnerable children in the borough are properly protected.
I have directed Haringey Council to appoint John Coughlan as Director of Children’s Services. Haringey Council will now remove the current Director of Children’s Services from her post with immediate effect.
Mr Coughlan is one of the most highly respected Directors of Children’s Services in the country – and I am grateful that he has agreed to extend his secondment to Haringey to manage the transition to new management.
My direction takes place under section 497A (4B) of the Education Act 1996. It takes immediate effect and will last until 31 December 2008. I will identify a new Director of Children’s Services to take up post from 1 January 2009 – and it is my intention to direct this appointment too.
As a result of my direction, Mr Coughlan will now be in charge of making all appointments in Haringey children’s services. He has decided that Libby Blake should be appointed as his deputy
So I am also directing her appointment. Ms Blake is currently seconded to Haringey from Kensington and Chelsea where she is Director for Family Services. I have asked Mr Coughlan to consider and address any immediate staffing issues raised by the Baby P case.
Mr Coughlan will consider further staffing capability in Haringey children’s services in the coming days. I am sure that he will have the full support of all Haringey staff as he prepares to implement the recommendations of the Inspectors’ report. I have asked Mr Coughlan and his successor to provide me with monthly reports.
I have also asked Ofsted to review the progress made on the implementation of the Inspectors’ recommendations and report to me by the end of June. On the basis of these regular reports and the report from Ofsted, I will then decide whether further sanction is needed – and in particular whether I should use my statutory powers to require the Council to enter into a contractual arrangement with an external provider for the delivery of some or all of its’ children’s services.
And in the mean time, if I am not satisfied that there is sufficient progress, I will not hesitate to intervene again.
But I believe that I need to go further now to ensure that all the Inspectors’ findings are acted upon across all local agencies and that all the lessons of the Baby P case are learned and acted upon.
It is unacceptable that the Serious Case Review into the death of Baby P was found inadequate. So I am also today directing Haringey Council, under Section 7A of the Local Authority Social Services Act 1970, to appoint a new and independent Chair of its Local Safeguarding Children Board.
Mr Graham Badman, who last week retired as Director of Children’s Services in Kent, has agreed to take up this post. He will start work this week. I have asked him immediately to begin a new Serious Case Review into the death of Baby P. He will submit the new Serious Case Review to Ofsted by the end of February for evaluation. And he will publish the executive summary of the new Serious Case Review – which must provide a full and comprehensive and fair summary of the full Serious Case Review – by the end of March.
This new Serious Case Review will require the commissioning of new management reports from – and the co-operation of – all agencies involved in child protection in Haringey. And all agencies must also now implement the wider recommendations made in the Inspectors’ report.
The Health Secretary is therefore announcing this afternoon that the Healthcare Commission will undertake an analysis of whether national child protection standards are being applied as vigorously as they should be, while the Chief Executive of the NHS will also ask all NHS organisations to review their child protection arrangements.
And I am pleased that both the Health Secretary and Police Minister Vernon Coaker are also making it clear today that the Healthcare Commission and the Metropolitan Police will co-operate fully with the new Serious Case Review into the death of Baby P.
With these immediate leadership and management changes; with the full implementation of all of the inspectors’ recommendations; and with the new Serious Case review; I believe that we can now address the deep-rooted and fundamental failings that have been identified in the tragic case of Baby P and more widely in Haringey.
When I met with the Chief Inspector this morning, she told me that in her judgement the failings in management, oversight and practice identified by the Inspectors’ report in Haringey are “exceptional”.
But this is no reason for complacency. As I told the House of Commons in my statement of 20 November, there is more we must do now and in the coming months to ensure that child protection arrangements are effective everywhere.
It is now just over five years since we published Every Child Matters in response to the Victoria Climbié Inquiry, chaired by Lord Laming. And while Lord Laming himself and the Joint Chief Inspectors in their report to me in July have said these reforms have significantly strengthened the framework for safeguarding children, there is still much work to do to ensure these reforms are being implemented robustly in every area.
Ofsted is today publishing its first evaluation of Serious Case Reviews, which highlights that there is variable quality across the country in conducting these Serious Case Reviews.
And Lord Laming has today written to me with a progress report and to set out his initial recommendations to strengthen the Serious Case Review process, including that all Serious Case Reviews are from now on independently chaired. Lord Laming will set out more details in his February report. But I want to take further action today.
So I am asking each Local Safeguarding Children Board responsible for a Serious Case Review which has been judged inadequate to convene a panel to be chaired by an independent person to reconsider the review.
I will ask Ofsted’s advice on whether that report satisfactorily addresses the issues rated as inadequate. And this same process will be used for any future Serious Case Reviews that Ofsted assesses to be inadequate.
Ofsted has also decided that each year they will undertake an unannounced inspection visit of safeguarding practice in every area of the country. And where areas have had more than one inadequate Serious Case Review, I will consider whether further action is needed.
I have today written to every Director of Children’s Services and Lead Member for Children’s Services in the country, enclosing a copy of the Haringey Inspectors’ report, to ensure that they are examining their own safeguarding arrangements.
I have also today accepted all of the safeguarding recommendations in the Joint Chief Inspectors’ report and published the government’s response.
In his letter, Lord Laming also raises the question of a public inquiry into Haringey Children’s Services. He says that he has been “struck by the robustness of the foundation on which current children’s services are based.”
He sets out his view that a public inquiry into the services in Haringey would set back the progress that has been made in many places and divert effort from the actions needed now to keep children safe in Haringey. I agree with this judgement.
For now, our priorities must be to:
– put in place the leadership and management team in Haringey children’s services that can ensure that vulnerable children in the borough are properly protected;
– appoint a new independent chair of the Local Safeguarding Children Board to begin a new Serious Case Review into the death of Baby P;
– and ensure that action has been taken across the country in response to those Serious Case Reviews that have been judged to be inadequate.
That is what I have done today. Nothing we do now can take away the terrible suffering that was inflicted on Baby P during his short life. The sad fact is that, as the Inspectors report makes clear:
“Baby P had been subject to a child protection plan from 22 December 2006, following concerns that he had been abused and neglected. He was still subject to this plan when he died.”
That is the most serious failing of all. We will not rest until we have the very best child protection arrangements in place in Haringey and across our country.