Baby P: What would you have done?

Peter Connelly, Tracey Connelly, Stephen Barker

In the wake of the full publication of the second Baby P serious case review, child protection consultant and trainer Perdeep Gill looks over the case history and re-examines the options that professionals on the case faced


A mother of four attends her GP with her youngest child (nine months old) who has a swelling on the head. She says she found him in the back seat of the car like this after he had been in the care of her mother. When the child is examined in hospital he is also found to have extensive bruising, minor scratches and discolouration to his nose. Doctors conclude the injuries are non-accidental. The mother claims not to know how the swelling occurred, adding that the scratches have come from her dogs and the baby bruises easily when playing. This last statement is disproved by further hospital tests. The hospital records that the parents of the child are separated and the mother has a friend (Mr SB) who she claims is never alone with her children. A strategy discussion at the hospital agrees there should be a joint investigation and a possible emergency protection order (EPO). The mother is interviewed under caution by the police and gives the same explanations as previously.


What would you do?
A Issue an EPO and put the child into foster care pending further investigation?
B Issue an EPO and put the child with his birth father?
C Gain voluntary agreement from the mother to accommodate the child with family/friends?


The child’s injuries are serious enough that an EPO is valid while the case is investigated. A voluntary agreement to accommodate the child if used should take into account the fact the perpetrator is unknown and could therefore be anyone including the mother or family/friends.


The mother agrees the child can be placed with one of her friends during the investigation. The health visitor reports the child’s immunisations are not up to date. The primary care mental health worker reports the mother has a history of depression but not mental illness. The mother’s history reveals she was taken into care after witnessing domestic violence by both parents and she was married aged 16. The husband says that the marriage had problems and, after the birth of the last baby and the mother met a Mr SB, he moved out. In observed interactions you see the baby smiles at the mother a lot and seems happy. The mother tells you she has recently learned her stepfather is not her real father and she is upset by something else that happened to her as a child.


During the case conference do you:
A Push for the child to be recognised as suffering neglect?
B Push for the child to be recognised as suffering physical abuse and taken into care?
C Push for the child to be recognised as suffering both physical abuse and neglect and taken into care?
D Push for the child to be allowed to return home to his mother as a subject of a protection plan?


During the course of the investigation the social worker should not forget that the original injuries were deemed to be non-accidental, the mother is in denial of this fact and the perpetrator is unknown. These are signs of high risk and show the child is suffering both physical abuse and neglect. The question that needs to be considered is whether a protection plan could work given the mother’s history and its implications on her parenting.


Social workers believe the child is suffering neglect only, however the conference concludes the child is suffering physical abuse and neglect. It’s decided not to pursue care proceedings but the child protection plan includes monitoring, family support, health and development checks, family and housing support and for the mother to go on a parenting programme. The mother agrees to get rid of the two dogs. The child is allowed home and the family moves house. As the new social worker allocated, you visit and feel the mother is affectionate with her children but note the baby is head-butting the floor. The mother requests for the dogs to be allowed back. The school reports the mother has slapped another of her children across the face and shouted at them. During a request for more contact the father says Mr SB is now the mother’s boyfriend. You question the mother and she admits that she would like a relationship with Mr SB who is living with her.


What would you do:
A Report the slapping incident and the new boyfriend to police and put all the children on child protection plans?
B Put the slapped child on a child protection plan but keep the baby on his original plan?
C Suggest solution-focused brief therapy for the mother and do nothing re: Mr SB?



The face-slapping incident and the mother’s request for the dogs to be allowed back indicate the current child protection plan is not working. Given the established concerns the conference needs to be considering the safety of all the children.

More needs to be known about Mr SB’s relationship and influence on the mother. The head-butting should also be investigated as a possible psychological response to harm.


Solution-focused therapy is suggested for the mother. Two months later she takes the baby to hospital with a swelling to the left side of his head and symptoms of illness. Mother states he was pushed by another child against a marble fireplace four days ago. Body maps indicate bruises and scratches on his face, head and body. Doctor accepts mother’s account of the injuries and focuses on the other symptoms.



What would you do?
A Refuse to let the child be discharged from hospital and apply for an EPO?
B Allow the child to be discharged?
C Seek the mother’s agreement to accommodate him elsewhere?


This is the second serious head injury to a child where there are child protection concerns. There are good reasons that an EPO could be successfully applied for while further investigations are done. It would also be reasonable to ask doctors to look again at the injuries in light of previous history.


The child is discharged home. The health visitor refers the baby to a child development centre for the head banging. The mother names Mr SB as next of kin on health records. On an unannounced visit you see a bruise on the baby. The mother initially says this was due to rough play with another child but later says he bumped into the wooden frame of a sofa. A hospital assessment notes grab mark bruises on the lower right leg. The mother says she grabbed his leg to prevent him falling off the sofa. The mother says a friend will be staying with the family over the weekend. The police say they want an EPO to be applied for.


What would you do?
A Don’t apply for an EPO because the bruises were accidental?
B Allow the child home if the family friend supervises contact?
C Apply for an EPO citing previous injuries likely to have been of a non-accidental nature.


This is the third incident of bruising to a baby where there are child protection concerns. There is enough evidence, given the child protection concerns previously, to apply for an EPO or care proceedings.


The child is allowed home without an EPO. At a child protection review conference you agree not all the injuries can be explained by the mother and the school nurse reports that the child’s weight has dropped from the 75th centile to between the 25th and 50th centiles.


What would you do?
A Apply to take the child into care?
B Put the child on a new child protection plan?
C Do nothing until the next meeting of the core group and a legal planning meeting can be organised?


The baby’s loss in weight is disturbing. Some of the baby’s injuries are likely to be non-accidental and this has occurred on a number of occasions. His age means he is highly vulnerable and the mother has failed to make any real changes in her life, neglect is escalating and she continues to deny abuse. The threshold for care proceedings has been met.


The school reports that the older children have been given authorised absence. The mother also misses one of her parenting classes. On phoning, the mother says she had to leave the borough to look after a sick uncle.


What would you do?
A Ask for details of the uncle’s house?
B Accept the mother’s account?
C Visit the family urgently at the uncle’s house?


This statement needs to be challenged particularly because this absence means she has missed appointments with professionals and the protection plan is failing. The family needs to be visited at the uncle’s house to check this is not a fabrication to conceal harm.


The health visitor reports that the baby’s weight has dropped to the 25th percentile. The baby also has an ear infection and a small bruise under his chin. Another child has a bruise under one eye. The mother says the infection was caused while she was trying to clean his ear and he struggled.


What would you do?
A Reconvene the child protection conference or call a core group meeting?
B Advise police of the new developments?
C Initiate legal proceedings?
D Wait until the scheduled legal meeting to take a decision?


The loss of weight is a significant warning sign. Further bruises on not just this child but another and the mother’s admission that she has accidently caused ear infection and the bruise are worrying. If not before, more urgency needs to be applied to thinking about the protection of this child. He has now suffered a lot of pain and neglect in a relatively short period of time.


A legal meeting takes place and it is decided the case does not meet the threshold for care proceedings. At a child development clinic numerous bruises are noted on the child and his weight has now dropped to the ninth percentile. The doctor believes the child is unwell and miserable due to a possible viral infection. The doctor advises the mother to take the child to the GP or the hospital if he does not get better. The police advise that prosecution will not be pursued.


What would you do?
A Call to find out about the doctor’s examination?
B Do nothing?
C Ask the doctor to do another examination given the child protection concerns?
D Ask for another doctor’s opinion before allowing the child home?


Given the child protection concerns in the family it is important that you follow up on scheduled appointments with other professionals and ask them to look at any symptoms with regard to the history of child protection concerns. The police should also be notified and it would be a good idea not to let the child home until the cause of the symptoms is established.

On 3 August, the London Ambulance Service responded to a 999 call at 11.35am. The 18-month-old baby was pronounced dead at 12.19 pm.

Expert comments on the SCR

‘There needs to be better information sharing’

Dick Henson

Dick Henson, detective chief inspector, Child Abuse Investigation Command:

This review shows we need better sharing of information. That might sound like a superficial answer but the fact is that you will never know the significance of what you know until you share it with other professionals. It also needs to be done in a timely way so you can achieve dynamic risk assessments. Any new information needs to immediately lead to an appraisal of whether it changes the risk assessment or the control mechanisms in any way.

We also need to come back to the adage “assume nothing, believe nobody and check everything”. So, if the removal of large dogs in a house containing toddlers is part of the child protection plan, you need to make sure the dogs aren’t just being hidden out the back somewhere. If a toddler has chocolate smeared on the face and there are child protection concerns, ask for the child to be cleaned up.

It comes down to all professionals thinking “what’s it like to be this child?”. In this case, even without the injuries discovered after Peter’s death, if all professionals involved had been thinking about how much pain he was suffering throughout their dealings with him and the family it would have focused the thinking on to the child more than the mother.

There are also lessons on effective supervision and ensuring that professionals do not become isolated.

If there is disagreement on a course of action, as there was here, then that needs to be recorded alongside the reasons for the dispute so it can act as a flag on a case when new information is received.

Social workers should feel empowered by SCR’s

Nushra Mansuri

Nushra Mansuri, joint manager for England of the British Association of Social Workers:

Given the bias of some parts of the media to target the social work profession, by reading a SCR we empower ourselves to be better informed about a case and, while not wishing to condone the blame game, we can talk about things going wrong in terms of not just one agency but the relevant agencies in a case in order to put a more balanced view across to others.

‘We need to learn more about infant survival’

Sue Woolmore

Sue Woolmore, child protection trainer and consultant:

What makes Peter’s story exceptional was that he lived as long as he did. One of the SCR’s lessons must be the need to gain understanding of infant survival.

Although Peter’s life ended with brutal force, he was also under constant threat from his unrelenting experience of fear and stress. The dysfunctional bond from his mother will have driven a wedge into Peter’s attachment to her.

Peter struggled on with outstanding courage, but other babies may lose that resilience, that will to live in the face of such a bleak and frightening existence. Their deaths may be inexplicable, despite the context of neglect and compromised parenting.

Date Published: 11 September 2010

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