15th May 2009
By Graham Clews
The failings in the Baby P case were caused by staff shortages, poor recruitment and a lack of awareness and communication among medical staff, a watchdog report has found.
The May 13 Care Quality Commission report into the NHS’s treatment of Baby P – now named as Peter – discovered systemic failings among the NHS organisations in north London that treated him before he died.
Staff working at North Middlesex University Trust and Haringey Teaching Primary Care Trust, which both use paediatric services provided by Great Ormond Street Hospital for Children Trust, had contact with Peter 33 times following his birth, the commission found. Baby P was taken to Whittington Hospital, which provides its own paediatric care, once.
Failures cited by the report included the fact that the hospital consultant who saw Peter two days before his death had no contact with his social worker; that health professionals did not attend case conferences in which Peter was discussed; and that child protection forms were poorly completed by health care professionals.
The commission also noted failures to follow child protection procedures by hospital workers. Poor recruitment and lack of training meant some staff, even those appointed by Great Ormond Street Hospital, did not have the experience in child protection that could be expected for their posts, the report added.
The report concluded that, since Peter’s death, improvements have been made at the trusts involved. It warned, however, that further improvement was needed.
CQC chief executive Cynthia Bower said the report had uncovered the failure of basic systems. ‘There were clear reasons to have concern for this child but the response was simply not fast enough or smart enough,’ she said. ‘The NHS must accept its share of the responsibility.’
The CQC is due to publish a second report into NHS arrangements for safeguarding children nationally in the summer.
NHS Confederation deputy policy director Jo Webber said that learning the lessons from Peter’s death requires not only improvements in systems and support for staff but also good leadership to create the right cultures to make these changes work properly.
‘The death of Baby P was a tragedy that had its roots both in a failure of systems across health and social care and of a culture that should have allowed professionals to share their concerns and work together more effectively,’ she said.
‘Central to making child protection work better will be leadership. Good leadership will not only improve the flow of information and the effectiveness of joint working between and within agencies but will also provide workers with the support they need to do their jobs better – particularly in terms of staffing, supervision and training.’
She added: ‘Allied to this however must be the fundamental understanding that child protection is everybody’s priority. All professionals across health, social care and in key agencies must help develop a culture that supports staff and encourages a questioning approach. Putting this in place is just as important as training, the measurement of process and the implementation of systems.’
