Information regarding Peters’ heartbreaking story can be found here. Please do not read if you are sensitive to stories related to child abuse. This one is particularly harrowing.
The frightning truth is, it will happen again in the not too distant future, as it has done over and over again in the past, until we are brave enough to reform our child protection procedures here in the UK.
A public inquiry into Peter’s death would be a good place to start.
What we DO know:
- Peter was seen by representatives from various authorities, including Social Services, The Police and the NHS, on average twice a week (or 60 times), and visited hospital 3 times in the 8 months leading up to his y death. We know they all failed him repeatedly, and some have paid with their jobs. It is easy, in the face of public outcry, to sack social workers and to hope that appeases people. But the real and lasting change the child protection system is so desperately in need of requires true, introspective analysis and transparent reflection of mistakes made across the board and their root causes, so that the government can the provide the APPROPRIATE training, resources and policies across the country to better protect vulnerable children who are today suffering as Peter suffered.
- We know that 12 crucial chances to save Victoria Climbie were missed 9 years ago. We were promised ‘Lessons learnt, never again’, after changes were apparently made following Lord Lamings’ Inquiry, and the government introduced the ‘Every Child Matters’ initiative and a new IT system with it.
- We know that Peters’ death, only a few streets away from where Victoria died, exposed the crisis that modern day social work is facing today. Social workers feel unable to speak their minds; they feel that they are not listened to and that managers overrule decisions sometimes based on a financial deficit. We know that it is not unusual for social workers to be forced to struggle with double the caseload recommendation (10-12). We know that they feel they have to spend too much time filling in forms when they should be spending time with families in order to make sound, fair and rational decisions in a child’s’ best interests. We know that morale is incredibly low, they feel disrespected, pressured, blamed for problems beyond their control, voiceless and powerless to do their jobs effectively. Some working on the front line are inexperienced, and training for new therapies, such as the one being piloted with baby Peters’ family is sometimes brief inadequate, with vulnerable children paying the highest price.
- We have heard the ‘rule of optimism’ and ‘too parent focused’ theories, the fact that there was a lack of urgency or healthy scepticism from the officials dealing with Peters mother, and that there was conflict between front line senior social workers like Sylvia Henry and social work managers like Clive Preece over the decision to take Peter into care or leave him with his mother. We have heard there was conflict with the social services and the police relating to the same issue and we know that for a brief time, Peter was in the care of a family friend who failed to tell authorities about the boyfriend. Haringey claim to have been unaware of the boyfriends existence and he was never questioned by police in relation to child cruelty charges before Peters death. At the time of Peters 2nd visit to hospital with bruising, despite ongoing investigation, police were not informed of his new injuries and social services did not investigate them, claiming the hospital did not flag up child protection concerns. The hospital maintains it did. Since then, even Great Ormond Street has been accused of trying to cover up its failings in Peters case. The fist Serious Case Review into this case was deemed invalid, due to it not being at all independent and because vital information (ie about the pilot scheme etc) was left out. We know both the police and social investigation into Peters safety were allowed to drift, ultimately paying a part in his death.
The government claims to be fully committed to addressing these problems.
What has happened since?
The second SCR, Lord Lamings Report and the Government Response.
You can read a summary of the final Serious Case Review into Peters death here
You cannot read the full Serious Case Review findings, as these are not public.
You can read Lord Lamings review of child protection services in England here.
You can read the full 58 point government response and ‘action plan’ here
The Final Serious Case Review
In summary, the final Serious Case Review into Peters death, headed by Graham Badman, chairman of Haringey’s local safeguarding children board, found that many opportunities had been missed to save Peter by ALL professionals responsible for his care, including social workers and their managers, doctors, police and other professionals. His death was ‘could and should’ have been prevented. It states that attempts to safeguard the Peter lacked “urgency, thoroughness and were insufficiently challenging” to his ‘mother’. The agencies involved were not fully focused on Peters’ welfare and “adopted a threshold of concern for taking children into care that was too high”. According to the report, and what is also glaringly obvious, is that Peter deserved much more from the services that were supposed to protect him.
Summary of Government response
- The government have introduced a ‘Chief Advisor on Safety of Children’, who will have a particular responsibility to influence and monitor the co-ordination of central government department policies and approaches toward safeguarding and to assess the extent to which the advice and guidance issued by professional bodies contributes towards effective multi-disciplinary working at the front line.
- Introduction of Government National Safeguarding Delivery Unit (NSDU) to give strong, co-ordinated national leadership across the system, Support Children’s Trusts Boards, local authorities, health and police, Monitor and challenge progress on the implementation of the recommendations in Lord Laming’s report.
- Ofsted have designed more rigorous inspection arrangements for safeguarding and will shortly be publishing a new framework for a rolling programme of inspections of safeguarding. Authorities will now have unannounced yearly inspections.
- An ‘ethics committee’ will now consider new therapy pilots and the appropriateness of their use in chid protection cases.
- The government deployed a ‘Social workforce’ headed by Moira Gibb, and have promised social work reform according to the task force recommendations by autumn.
- In April, Ofsted set up a ‘hotline’ for children’s services workers who are concerned about practise in a pilot scheme. It was not continued after the pilot.
- The government promise to change the ICS system social workers use to record information.
- Government pledge 73 million for social work reform. Though it is important to note that since then, serious doubts have been raised about the governments commitment to the cost of proposed and highly needed reforms.
- Government has announced a Return to Social Work scheme to help former social workers move back more easily into the workforce.
- Government have promised to improve delays to care proceedings, though have yet to ‘finalize’ how they are to do this.
- Francis Plowden has been appointed to conduct a review of court fees, and to establish whether court fees act as deterrent when local authorities decide whether or not to commence care proceedings.
Questions that STILL remain unanswered:
- Crucially, Haringey maintain that they had no idea the Boyfriend was living with Peters ‘mother’. But there is a lot of evidence to suggest otherwise. Haringey missed over 7 chance to expose the boyfriend:
a) The VIDEO.
During a piliot video made by senior social work manager Susan Gilmour, Peters mother speaks at great length about her ‘friend’. She uses his name, talks about cooking him a valentines dinner and says he has been making the garden nicer for the children.
b) At the first case conference to discuss injuries to Peter, the boyfriend was mentioned by his first name.
c) Peters real father told Social Workers he believed the mother had a new partner.
d) Peters maternal grandmother claims to have told Social Workers (while her daughter listened in upstairs) that the boyfriend was ‘here (at Peters home) more than her’ and that she ‘wouldn’t be surprised’ if he had moved in. Haringey have no record of this.
e) A family support worker met the boyfriend at the family home.
f) While at the parenting classes organised by Social Services before Peters death, his mother talks about being pregnant. Noone thinks to ask who the father of the baby is.
g) Peters mother openly discusses her new relationship on social networking sites.
Statistics from the NSPCC show that a child is up to 33% safer when living with its natural parents, as opposed to stepparents. Without victimisation, this area needs to be investigated more by Social Services and Social Workers made more aware of the potential dangers, as well as what to look for.
Haringey maintain if they had known about the boyfriend they would have acted very differently toward Peter, and blame the mother for her manipulation, which is a factor the government have tried to address. However, what if Social workers are under so much pressure that they subconsciously choose not to see dangers that might cause a lot more paperwork, or do not want to cause more ‘problems’ and be seen as trouble makers among their colleges? The evidence certainly suggests Haringey chose not to see this danger. Why? What can be done to prevent this, not only in Haringey, but across the country?
- Children on the ‘At-Risk’ register have an electronic file to record their story. If a child dies in suspicious circumstances, it is the ‘locked’ as it becomes evidence in possibly a criminal investigation. Panorama reports that Peters file was accessed TWICE, illegally, after his death. Haringey claim it has been investigated and no data was altered, but the police maintain there has been NO INDEPENDENT FORENSIC INVESTIGATION into who accessed the files and if anything was changed.
- Perhaps even more worryingly, there is evidence to suggest Social Services withheld information from the police, even after Peters death, and when his mother was being investigated for child cruelty. The police would have been VERY interested to know about the existence of a ‘male friend that helps out’, even if it is only to eliminate him from inquiries and get another witness statement about the ‘mothers’ parental ability. Despite there being a note on Peters electronic file from Susan Gilmour detailing information about the pilot scheme and her interview, this information WAS NOT on the document received by police investigating the charges. They NEVER saw the video and none of this evidence was used as part of the murder trial that the 3 suspects were acquitted for.
- How did the police allow the child protection investigation to drift so drastically? How could the police drop the investigation into cruelty charges the day before Peter’s death? Why were the police not open to alternative explanations about the person who could have inflicted Peter’s injuries? Maybe communication with Social Services was to blame or maybe information was withheld, these questions remain unanswered. The government report does not adequately address the role of The Police in these issues.
- A few months prior to Peters’ death, an Ofstead report rated Child Protection at Harringey to be ‘excellent’. When inspectors returned after the conviction of Peters killers’, Harringey failed. The NSPCC statistics show that on average 1 child a week dies from cruelty in the UK, and that child is as likely to come from an area with a good Ofsted report as those with bad ones. Maybe Ofsted inspections do not adequately measure the authority’s ability to cope with the real factors that put a child at risk of serious harm. If Haringey staff were able to manipulate data etc to make themselves look good, what is to stop this from happening in other authorities across the UK? How much confidence can we have in Ofsted ratings?
The government response and Lord Laming’s report both ignore an important issue that has been raised by many workers on the front line against child abuse. This is that the ‘Every Child Matters’ initiative may make identifying at risk children akin to finding a needle in a haystack. This issue needs to be addressed. Most children who die from cruelty and neglegt in the UK are still unknown to Social Services, this is a major problem that we need to be working to solve, not make even more difficult.
- Wes Turnell from the NSPCC says the statistics that measure deaths from cruelty in the UK have not changed for the past 30 years, and he believes they will not change until we see major reform. The government needs to address why our child protection system seems to be ineffective at reducing child deaths from cruelty and neglect.
What Is a Public Inquiry and What Are They For?
‘A Public inquiry is an official review of events or actions ordered by a government. A public inquiry differs from a Royal Commission in that a public inquiry accepts evidence and conducts its hearings in a more public forum and focuses on a more specific occurrence. Interested members of the public and organisations may not only make (written) evidential submissions, as is the case with most inquiries, but also listen to oral evidence given by other parties.
The conclusions of the inquiry are delivered in the form of a written report, given first to the government, and soon after published to the public. The report will generally make recommendations to improve the quality of government or management of public organisations in the future.’
The Prime Minister orders a Public Inquiry when it is considered to be in the public interest. The Inquiry into Victoria Climbie’s lonely death did not prevent Peters, less than a few streets away and less than 10 years later. The promises of ‘lessons learnt’ then appear to be empty. How are we to believe the exact same promises, from some of the very same people, now? If there are fundamental flaws in our Child Protection System, we cannot shy away from exposing them, we MUST act now to uncover the problems so that we may begin to find solutions.
There is CLEARLY a problem with getting to the truth in Peters story, for example, the hospital claiming they told Haringey about their child protection concerns on Peters second hospital visit, and Haringey denying this. Many discrepancies like this can be found in Peters story. How much information Haringey had about the Boyfriend, and how much they shared with the Police. Why was Peters electronic file illegally accessed twice after his death, by whom, and why? Haringey, the Police, the NHS and the government have all been accused of trying to cover-up their mistakes, and in some cases there is considerable evidence that this is true. If the government wish to restore confidence in their ability to protect children, they must begin with facing the real problems, starting with a Public Inquiry into Peters death.
If the government is serious about protecting children, they must be, (and they must force all agencies involved to be) completely transparent in their admissions about the case and about the problems at whole. It is nearly impossibly to believe that Haringey is one ‘bad apple’ in a relatively well functioning system; actually, many experts in child protection have called the system ‘un-fit for purpose’. The results of a Public Inquiry would provide invaluable information for child protection authorities across the country, and a chance to implement changes so that the chances of ‘another baby P’ are very slim, as opposed to certain as things stand now.
A Public Inquiry into Peters death and child protection at Haringey is in the best interests of the public and is in the best interests of the Social Workers who feel they are reaching crisis point, who feel they are unable to do their jobs properly and effectively because of a defunked system. It is most certainly in the best interests of vulnerable children who are suffering, right now, as Peter did. It is in the best interests of the child that will die probably in incredible pain, maybe starving, feeling unloved, alone and completely unable to defend his or herself, somewhere in the UK this week.
Vulnerable children with no voice who are completely unable to defend themselves need the government to fully commit to transparency and ownership of the problems that hinder child protection, so that we might find solutions.
The government have the opportunity to ensure that Peters death is not in vain. His legacy should offer better protection to children like him surviving in the UK today.
NO LIP SERVICE, NO FALSE PROMISES, NO WHITEWASH. REAL, LASTING AND EFFECTIVE CHANGES.
Thank you for reading.
Sleep tight little man xxx