Haringey child protection agencies should have saved Baby Peter from the abuse that led to his death but did not because of their uncritical acceptance of his mother’s claims and a failure to carry out “authoritative child protection practice”.
That was the damning conclusion today of the second serious case review into Peter’s death in August 2007, which followed the sentencing of his mother and step-father and their lodger, Jason Owen, for causing or allowing his death.
Contrast to first SCR
The conclusions of the review panel, chaired by Haringey safeguarding children board’s independent chair, Graham Badman, were in stark contrast to those of the first SCR – dubbed inadequate by Ofsted and published last November.
This had found “numerous examples of good practice within all agencies” and that, “with the possible exception” of a paediatric assessment conducted two days before Peter’s death no single factor on its own would have led to him being saved.
Care proceedings should have been issued
The second SCR concluded that Haringey Council should have issued care proceedings in December 2006, following a child protection conference. It said a “legal view” following the conference, confirmed by email a week later, had concluded the threshold for care proceedings had been met.
The conference came 11 days after extensive bruising was found on Peter’s buttocks, face and chest by a paediatrician, who concluded that they were non-accidental injuries, and with his mother and grandmother under police investigation.
Non-attendance at child protection conference
However, neither his GP nor the paediatrician who examined him attended the conference, and while the majority of participants were not child protection specialists, they were given responsibility for deciding on a course of action by the chair.
The review said: “It is difficult to understand how Peter could be returned to the family home after he [had] been seriously injured, possibly deliberately by an adult, and there is no resolution of who did it.”
A review child protection conference was held in June 2007, after more injuries were found on Peter by health professionals, but attendance was poor. The police did not send a representative despite believing the injuries were non-accidental and that the child should be removed.
Though this conference was told that a legal planning meeting was due to be convened within the next week, this took seven weeks to arrange due to “administrative failures” and a “lack of urgency” from social work managers.
The review concluded: “To make a wrong decision is regrettable, but to lack urgency in facing up to making it is unacceptable.”
‘Too willing to believe mother’
It said agencies were “too willing to believe [the mother’s] accounts of herself, her care of the children, the composition of her househould, and the nature of her friendship network”.
Though the initial child protection conference noted the existence of Peter’s stepfather, as a “friend of the mother’s”, the review found that “a significant deficit…which was then perpetuated” was agencies’ failure to establish his identity and conduct background checks on him.
It added: “One of the potentially dangerous scenarios in child protection is an unrelated man joining a vulnerable single parent family. [The mother’s] account of his role was accepted too readily.”
The review found agencies repeatedly gave Peter’s mother unchallenging messages about her “poor parenting”. For instance, her two older children were not placed on the child protection register after the December conference, despite all four “experiencing a degree of neglectful care”.
It said the decision to place Peter with a family friend from December 2006 to January 2007 was a “clear indication” that the injuries were not being taken too seriously and that agencies wanted to keep the family together.
Low level of concern
It added: “The implications of the inter-agency and local authority actions appeared to be that this kind of occurrence was not surprising in a family like this. The level of concern was too low.”
What should have happened was “an authoritative approach to the family, with a very tight grip on the intervention”, including “clear targets” with “short timescales”.
The review found “too little significance” was given to her own childhood experience of neglect and alleged abuse and said a challenging approach “would have brought to the surface the emotions deriving from her deprived background” and “probably be reflected in anger, evasion, resentment and protest”.
Badman said: “I believe the most important lesson arising from this case is that professionals charged with ensuring child safety must be deeply sceptical of any explanations, justifications or excuses they may hear in connection with the apparent maltreatment of children. If they have any doubt about the cause of physical injuries or what appears to be maltreatment they should act swiftly and decisively.”
Haringey Council leader Claire Kober said: “We accept that things went badly wrong with our child protection services in 2007. There were opportunities to help this family which should have been taken. I apologise for those failings.”
She said the council and its partners were implementing all the recommendations in the second SCR and from the damning joint area review of safeguarding published last December, but recognised there was “much more to be done”.