Systemic failings in NHS contributed to death of Baby P

The NHS must accept its share of responsibility for the death of Baby P, the 17 month old boy who died at the hands of his mother, her partner, and their lodger, the new independent regulator of health and social care in England has said.

A report by the Care Quality Commission found systemic failings in the health care provided by NHS trusts to Baby P, whose first name has been revealed as Peter.

Excluding his birth, Peter had 34 contacts with health professionals at North Middlesex University Hospital NHS Trust and Haringey Teaching Primary Care Trust, in north London. Paediatric staff in these hospitals was provided by Great Ormond Hospital for Children NHS Trust.

The commission said it was concerned that the boards of all the trusts with which the baby had contact had previously declared themselves as complying with all the core standards related to safeguarding children.

The commission’s chief executive, Cynthia Bower, said, “There were clear reasons to have concern for this child, but the response was simply not fast enough or smart enough. The NHS must accept its share of the responsibility.”

She added: “The process was too slow. Professionals were not armed with information that might have set alarm bells ringing. Staffing levels were not adequate, and the right training was not universally in place. Social care and health care were not working together as they should. Concerns were not properly identified, heard, or acted upon.”

The report says that poor communication between health professionals and between agencies meant that urgent action to protect Peter was not taken. For example, the consultant who saw Peter two days before his death did not have any contact with his social worker, and health professionals did not always attend child protection conferences to discuss Peter’s case.

Child protection procedures were not always followed. For example, skeletal x ray surveys that could have shown up the scale of his injuries were absent, and the use of parallel growth charts to monitor Peter’s development was not routinely documented.

The commission accepts that since Peter’s death the trusts involved have made progress in reducing gaps in child protection procedures but says that more work still needs to be done. The report recommends that all staff members are clear about child protection procedures and be trained in safeguarding children to a level appropriate to their role, as set out by the Royal College of Paediatrics and Child Health.

It also recommends that trusts have enough properly qualified paediatric staff available, in line with established guidelines. It states that Great Ormond Street Hospital must review the adequacy of consultant cover at St Ann’s Hospital, Tottenham. At the time of Peter’s paediatric assessment on 1 August 2007 four consultants should have been in post, but there were only two.

The commission is currently carrying out a national review to ensure that all NHS trusts in England are meeting their obligations to safeguard children. This report will be published in the summer.

Tracey Baldwin, chief executive of the Haringey primary care trust, said, “We are deeply sorry for this tragedy and apologise without reserve for the failures identified in this and other reports. We failed to understand the level of danger that Baby Peter was in and what he needed to be safe.

“The Care Quality Commission report follows the independently chaired—though as yet unpublished—serious case review, which together clearly identify what went wrong with Baby Peter’s care and protection. They have both made substantial recommendations about what needs to change, which as the report states we are implementing.”

Clare Panniker, chief executive for the North Middlesex University Hospital NHS Trust, said: “We welcome the publication of this review and its recommendations. We also recognise and apologise for shortcomings in the paediatric services based on our site that contributed to baby Peter’s tragic death.”

She said that the trust had already put in place a number of improvements to the service in terms of communication, supervision and training. In addition, the paediatric A&E service was now available around the clock. This year the trust was planning to appoint a new consultant in accident and emergency with a special interest in paediatrics and a new consultant paediatrician with a special interest in accident and emergency.

A BMA spokeswoman said: “This report shows how the NHS failed Baby Peter, but its recommendations go some way towards ensuring that children will be better protected in the future.”

She added: “Our recent guidance for doctors dealing with child protection issues should help them support children they are looking after. Our message to doctors is that if they believe a child in their care is at immediate risk it is their duty to take the necessary action to safeguard the child or children in question.”

A spokesperson for the Royal College of Paediatrics and Child Health said: “We are pleased that the Care Quality Commission recognises the importance of safeguarding training and our training programmes. Providing training is vitally important, but we also need to ensure that staffing levels are appropriate. This is something that we are taking very seriously, and we will continue to press the government on this.”

The Care Quality Commission brings together independent regulation of health, mental health and adult social care services for the first time. Before 1 April 2009 this work was carried out by the Healthcare Commission, the Mental Health Act Commission, and the Commission for Social Care Inspection.