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Death of Baby Peter

On 3 August 2007, Peter Connelly (known as 'Baby P' or 'Baby Peter') died aged 17 months old, after sustaining severe injuries over an 8-month period. NHS health professionals had cared for Baby Peter on multiple occasions during this time. On 11 November 2008, his mother Tracey Connelly, her boyfriend Steven Barker and his brother Jason Owen were convicted of causing or allowing Baby Peter's death. A doctor failed to spot the child’s severe injuries

Following his death, an internal serious case review had been produced by Haringey Council. In December, Ed Balls asked for Ofsted to investigate the safeguarding arrangements at the council. The Ofsted findings suggested that there were significant weakness in the safeguarding and child protection arrangements in Haringey and criticised the serious case review which had been undertaken by the council.

In May 2009, the Care Quality Commission (CQC) published a report into the failures of the NHS organisations which had been involved with Baby Peter prior to his death in August 2007. The report focused on North Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust, Great Ormond Street Hospital for Children NHS Trust and the Whittington Hospital NHS Trust.

The report suggested that poor communication between health professionals and across agencies, such as social services and the police, meant that urgent action to protect Peter had been delayed. Additionally, staff involved in providing care for Peter did not consistently follow child protection procedures. Staff were also lacking experience in child protection issues. Another significant shortcoming highlighted by the report was the fact that healthcare staff at one trust were not clear on where responsibility lay for following up on social services referrals and were unclear on their roles in regards to safeguarding children.

The CQC was particularly concerned that three of the trusts concerned had provided assurance that they were compliant with child protection standards. As a result, the CQC announced that it would ask all trusts in England to detail the arrangements they had in place for effective child protection, in adherence to government core standards and national statutory guidance.


Care Quality Commission.
Care Quality Commission publishes report on the NHS care of Baby Peter.
Care Quality Commission; 2009.

Ofsted, Healthcare Commission and HM Inspectorate of Constabulary.
Joint area review; Haringey Children's Services authority area; review of services for children and young people, with particular reference to safeguarding.
Ofsted; 2009.