Serious Case Reviews – Baby Peter and beyond

Here’s my latest column from the Ham & High:

I have reached the next stage in my quest to get the Serious Case Review into Baby Peter’s death published – and beyond Peter – the publication of all Serious Case Reviews. A Serious Case Review (SCR) is produced immediately after any such case by the agencies involved in that child’s care. It tells the chronological story of who did what and when. It is an invaluable document – but it is kept secret.

I have been battling to change this. I have asked the Information Commissioner to find in favour of publication in the public interest. I don’t believe that the ambition of that over-used phrase ‘lessons must be learned’ can ever be fully realised if the causes and actions are hidden as they currently are.

The Information Commissioner recently came back to me to ask for more information as to why I thought it would be in the public interest for the SCR to be published. I sent him my reasons (below) and now the Information Commissioner is going back to Haringey Council for further information.

As I await the decision – although I have previously blogged about this – I regard continued public scrutiny as so important that am putting all of this in the public domain again.

This was my email in response to the Information Commissioner’s request:

Having been Leader of the Opposition on Haringey Council when Victoria Climbie died and now MP in half of Haringey during the Baby P tragedy – I have come to the conclusion that a contributing factor to cases like these (and others) is the secrecy, the closing ranks culture and the lack of transparency.

The Serious Case Review (version 1) which I was allowed to read virtually under lock and key in the Department of Education (where I could not make notes or record any part of the document) was an eye opener to me. The executive summary of the same document which is published did not reflect the key problems, in my view, that were at least part-causal in the eventual tragedy.

The thing that struck me most was the litany of casualness with which people did their jobs (appointments missed, not followed up; files lost, handovers not done, meetings not attended). There was a litany of failures like these at every level, virtually by every person and every agency. I think that most people would expect that once a child is on the protection register and their case being brought to the Safeguarding Board – that there would be a rigour about all aspects connected with them.

This casualness and lack of care is only really demonstrated if you get to read the whole document. It does not come through in the summary and itself is cumulatively causal in my view.

Literally hundreds of professionals across the country emailed me about their knowledge and experience – as did the general public. I believe that the phrase which is dragged out ‘lessons will be learned’ won’t be fully possible if the facts of the case and the failures in the case are kept hidden. As I say, the Executive Summary does not reveal the extent of the small, but cumulative failures – which I believe many professionals would recognize in their own fields and therefore be able to do something about. Therefore it must be in the public interest to be able to see the whole document.

Simply issuing another 150 Laming-like recommendations every time a tragedy happens simply adds procedures that take professionals away from their work without ever being able to see the why and wherefore of such recommendations – nor to judge or be able to critique the new ways from an informed position. The issues are kept between local authority, the other agencies and the Government – so keeping out those who would, could and should benefit from reading the whole story.

I am not an expert nor a professional – but unless and until we really open out all the issues around cases such as these – there will continue to be an air of defensiveness and self-protection which work against the safety and well-being of children at risk.

Social workers need to work in an atmosphere of support and good management – which can only come from opening up the real events, letting them stand there for all to see – and those in the professions taking those lessons away.

The argument Ed Balls makes to me against publishing the Serious Case Review is that staff would not speak freely if they knew that what they said might be published. My view is that anyone working in any field where there is such an event has a duty to speak and say what happened. They would have to if the case goes to public inquiry or hearing. Names and personal information should be anonymized. It was anyway in the SCR I read and social workers were referred to as social worker 1 or social worker 2. It is also the case that quite a lot of time elapses between the event and the publication as the SCR is written immediately (usually) and the case and the trial and exposure comes much later.

OFSTED did an audit of Serious Case Reviews and found that nearly two thirds, I believe, were inadequate. So – additionally – this would not have come to light without OFSTED’s exposure. If they were published – these inadequate SCRs would have been exposed much earlier. So – whilst the Serious Case Review I am most concerned about is obviously the Haringey one – it is clear there is a wider issue too.

So – I believe it is totally in the public interest for the Serious Case Review to be published. Secrecy, lack of transparency and openness and closing ranks are at the heart of the problem in Haringey.

I hope you find in favour of publication.

Kind regards
Lynne Featherstone

0 thoughts on “Serious Case Reviews – Baby Peter and beyond

  1. it was a terrible thing but justice delayed is no justice so if you spend ages going back and forth regarding the subject it just becomes a farce so actually people should be held to account as to how long they take to reply ect. one week is enough. regarding all those visits to baby p and all that paperwork and all those workers and department heads and on and on for a poor misguided delinquent familly. hm . its called the smothering of the country by legal machinery and false legality. privalege favours monopoly and we have to much of both at this time.

  2. ___________________________


    Baby P was 17 months old when he was tortured by his mother’s boyfriend in spite of 60 visits by social workers and 3 visits to hospital. It all culminated with a visit from a specialist paediatrician who failed to notice that he had a broken back, 2 finger tips sliced off, several finger nails pulled out, 12 broken ribs and bruises all over his face and body concealed by chocolate. He would still be alive today if someone just once had given him a cursory physical examination but this was not done, probably because as usual Social Services etc. were intimidated by this brutal child abuser living in smelly and sordid surroundings with his sluttish partner and his Rottweiler dogs so they left the horrible family alone to look for easier prey; mostly amongst respectable and responsible households.

    Most people seem more intent on wreaking vengeance on the murderers of Baby P than preventing the same situation occurring again; may I therefore make a suggestion?

    Social Services plead shortage of staff and financial resources as excuses for overlooking torture of children (even after 60 visits to Baby P). In other European countries they take children from parents only if they have been severely physically or sexually abused but in Britain we waste most of out valuable resources fighting cruel cases in secret and costly courts to remove children and even new born babies at “risk of emotional harm” and for similar lesser reasons. The parents of Baby P would never have gone to court to fight for his return if he had been taken earlier as parents that violently physically abuse their children avoid courts like the plague!

    Physical torture KILLS KILLS KILLS!!!
    Emotional abuse does NOT
    Poor school attendance does NOT
    A cluttered house does NOT
    Witnessing domestic violence does NOT
    Hostility to the “professionals” does NOT
    A parent with learning problems does NOT

    Where therefore should the “SS” priorities lie?

    I’m only asking!!

    I would have thought myself it was MORE IMPORTANT to concentrate on preventing babies being tortured rather than the more common rush to remove babies AT BIRTH from mothers whom some highly paid psychobabble merchants have decided may at some future date emotionally harm their babies!Crystal ball gazing?

    If all the resources of child protection were used to examine thoroughly (looking for visible bruises and burns) say once a month, all those children suspected of having been seriously physically or sexually abused thousands of children’s lives would be saved. At present our resources are wasted fighting in courts to remove happy healthy children from their parents for risk of emotional abuse and similar non life-endangering symptoms. Only parents that truly love their children fight through the gruelling ritual of the secret family courts and against all common sense they nearly always lose. If they dare to protest publicly more than 200 parents a year are jailed (answer to a parliamentary question) for breaking the “omertà” wall of secrecy!! If only mothers facing a life sentence by losing children to forced adoption had the right to a hearing by jury most of the present injustices would disappear. In short, what is needed is simply concentration on eradicating physical child abuse and then introducing hearings by juries who would rarely take children in other cases such as “emotional abuse”, cluttered dwellings, poor school attendance etc.

  3. In the aftermath of tragedies such as the Climbie case the institutional focus, and the public reaction, is on finding out WHO is to blame so they look for individuals carrying the responsibility for the tragic event.

    In any follow up investigation/enquiry, the focus should be entirely on the system of care so that instead of hunting for an individual or persons to sack they should look only at the system itself to look for what really went wrong in great detail. In this case it sounds as though the evidence points to multiple small failures cumulating in the tragic death of an infant. It sounds like systemic professional failure at all levels.

    If the evidence in the Climbie case remains unpublished, social welfare administrative case reviews will inevitably continue to support existing structures by looking for individual scapegoats. Open publication would allow social workers, social work students and educators and other related professionals to modify detailed professional practices leading to lasting professional improvements in services. If anything was ever deemed to be iin the public interest, this is very clearly at the top of the list.

    Ths is why I fully support Lynne Featherstone’s campaign to have this and similar enquiry documents in the public domain.

  4. i whole heartedly agree with your item regarding Baby Peter.
    Its is just astonishing that a child already known to be at risk , was allowed to die in such a vile, and abusive way.
    Under the noses of his protectors.
    Thank you for following this case for us, and using your vocie to speak for every sane human being in the country.

  5. I have not yet recovered from sorrow and horror regarding the death of Baby Peter. it It haunts me as do all the injuries and deaths of hundreds of other unnamed infants who suffer incredible and life threatening injury from abusive and ignorant parents. Why is it that in this so-called child centred socieity we fail to take appropriate action to step in and save those too young to save themselves. It is intolerable and unbearable.

    Like those who have spoken before me i agree there is balme to be aportioned not only to those parents but to social workers, managers, nurses, doctors and the like. This is the whole system. It is a total system break down. One that we have seen replayed over and over again. As unversity lecturer I am well aware, with my students, of the rulings that are now in place to dissolve any former inequality between us. I relish that. Their voice opens us to their experiences – not all good. We have become experts in the so-called dissolution of the ‘conspiracy of silence.’ Sexual abuse is now brought into the light and dealt with like never before. Battered wives can speak up and find support. Vulnerable adults live in supported housing and have become members of our communities. The homeless are housed. Immigrants sheltered. The unemployed paid. And our infant – defenceless, speechless, hidden behind walls???? It is this aspect that is SO treacherous, SO dispicable that there is no safety for these youngsters. no place and no-one to go to. No help. Exactly for those reasons there must be a public voice.

    This present reluctance to publish the Serious case Review seems to be wholly designed to protect the so-called protectors, the professinals, those in post in that broken system. But if silence still exists behind the doors of those in power how on earth are we ever going to change this utterly deplorable state of affairs. We will no longer stand in the dark and let our infants be tortured and murdered. Their case is our case and as mothers of children, teachers of students, wifes of husbands, we demand that silence be over and the full facts revealed. Otherwise there will be no change and we can simply expect more hatred and cruelty acted out on defenceless and voiceless children.

    I am totally and completely in support of Lynne Featherstone’s efforts in the light of the case of Baby Peter that the Serious Case Review be published and made publically available as an indispensable part of creating fundamental change in safeguarding infants and young children.

  6. Blaming the system? Blame instead those who would not speak out, and those above them who they were afraid of, those who bullied them – those who should speak out were afraid of being penalised for speaking out. These systems are created and run by people.

    Publishing is part of the information society. That we would get to this state was heralded in Alvin Toffler’s 1980 book The Third Wave – he advocates an open society with all that that entails, but at the same time there have to be methods to stop witch hunts.

  7. I was the chair of Haringey Foster Care at the time of the Victoria Clumbi case. I said then the problem is that someone will be the scapegoat, and I still think that is what happened. I do think we should be aware of how these event take place, however we also understand some of the problems. To large a case load for Social workers, and also a large bureaucratic organisation that needs breaking down into smaller manageable units. We also need to bring back the common sense factor. In a job like social work and care, in our current culture everyone is so concerned at protecting their back, which I believe costs, and the cost is paid by the client, i.e. the children. Let us have smaller social services structures with people who are able to respond quickly to need and are not so afraid of being hung out to dry that they do the right thing, even though it might mean pulling against the very long rules. It is often not the rules that are wrong but the way they are applied.

  8. Adrian ,the “culprit” is the responsible local authority, HARRINGEY !
    Wasting valuable resources chasing loving mothers through expensive court procedures taking babies and toddlers for risk of emotional abuse and similar NON life threatening irregularities whilst severely physically abused children are callously left to die. Baby P and many others at risk of continuing physical abuse only needed regular and thorough physical examinations .Countless lives would have been saved if this had been done and it is not too late to arrange these .Battered babies do not make good adoption material however so I have no doubt the “SS” will continue to persecute mothers for trivialities and Baby P will have died in vain !

  9. Great e mail to the commissioner outlining why you feel the SCR should be made public. But it seems such a shame that you really need to ask. Secrecy and silence constituted the backdrop to Baby Peter’s murder. THere is no excuse for continuing with it.

  10. I have seen several summaries of Serious Case Reviews Reviews and found them uninformative. I think there are at least two problems with the social services, one is weak management and the other is the ‘revolution’ in communication which means that everybody is emailing and voicemailing everybody else and rarely getting a reply.

    I have just been through several months of struggle trying to get a mildly mentally handicapped elderly man for whom I am a trustee into residential care. He is not even in need at present of Council funding but is able to pay himself. I have two pages of phone numbers for social workers and similar people. I never speak to the same person twice. They are all kind, helpful and pleasant people but cannot in the circumstances get a grasp of the actual situation. I even had a call from a social worker who was trying to contact another social worker about a problem with this man and could I please help her. As it happened I could and did. Fortunately there was enough support from friends and neighbours and I am a professional and we managed.

    Social workers need very good support. They have the most serious responsibilities laid on them, children, mental illness and the elderly. Is that more or less heavy than the responsibility of deciding whether or not to go to war? They don’t make a case for themselves and they must if anything is to change. Chid Constables know this very well. If the police were ignored and slighted as social workers often are the phones in the Home Office would be red hot. But there are no votes in social services.

  11. With respect Jane Kitto you are NOT spot on! If social workers concentrated on removing children for life threatenig causes (eg physical abuse) instead of trivialities (eg risk of emotional abuse) involving cruel and expensive court cases they would be much better regarded !

  12. The secrecy serves only to protect the government while acting AGAINST the interests of the public in general and vulnerable children in particular.

    Information about the shortcomings of the Social Services and the National Health Service involved with Baby P should be published forthwith, for reasons of client/patient safety.

    I suspect that the truth about Social Services and the NHS is just too embarrassing for the government and others in positions of authority, so they are trying to prolong suppression for as long as possible.

  13. Ian Joseph says It is ‘HARINGEY’ that is the problem, the difficulty with that statement is that Haringey is an organisation, we need to be able to talk to people and people are the ones who have to take responsibility, Haringey in that sense can not be blamed or talked to, and in a big organisation like Haringey it is possible to pass things from one to another and no one will say ‘the buck stops here’, which is why I say we need smaller not larger bureaucracies if we must have them.

  14. No Adrian in the case like so many other cases it is the high priorities given by those running organisations like Harringey to non life threatening parental defects (risk of emotional abuse etc) and low priority given to physical abuse that can kill unlike other West European countries where thank goodness the contrary is true.
    Social services have discretion as to which children they seek to remove and if those in charge told them to stop wasting time chasing mothers desperate to keep their children through the endless procession of family courts and concentrate instead on monitoring all those known to be in danger of physical abuse and removing only those who actually have suffered sexual or physical abuse then countless little lives would be saved from brutes who would never go near a court or even try to recover any battered children that had been taken from them;Simple instructions to social workers from those in charge to concentrate on saving lives instead of terrorising loving but mildly imperfect parents would have the desired effect.

  15. I think it’s a shame Ian that you so often (as in comments I’ve seen you made elsewhere) are so dismissive about emotional abuse, as if it doesn’t really matter. Emotional most certainly can kill – as when it drives people to committing suicide.

  16. As I remember Mark,BABY P,Victoria Climbé,Maria Colwell, and others were all killed by physical abuse.No babies have ever been killed by “risk of emotional abuse” so why remove them at birth for such a trivial and remote possibilty?
    What child has ever committed suicide with a coroner’s verdict of “emotional abuse from its mother”? NONE.
    I do not dismisss emotional abuse ( except when it is forecast rather than something that has actually happened) It is a matter of PRIORITIES so preventing physical and sexual abuse should be given top priority over other more trivial parental defects especially those that are mere predictions of what someone thinks might happen rather than anything that actually has happened !

  17. Emotional scars can hide behind the facade of …….a smile? Where the signals for spotting emotional distress are often hidden in the age of technological advances?
    How of have you seen texts between people sitting almost next to each other? Eyes aren’t called the windows of the soul for nothing!
    And don’t rely on the Coronial System to get it right! We have a major problem with enforceable regulation,where if failures occur somebody should be held to account……but they are not and many management teams are acting with total impunity in the face of such passive regulation.We are using inadequate funding and poor training as a reason, why front line workers often fail. They also fail because the case loads are excessive and they are tired beyond observance. Maybe some of management’s renumeration and severance packages could help fund an adequate system?

  18. As with Victoria Climbe, when the systems say “this must never happen again, they usually seem to mean “until the next time, when we will review and investigate it and reach the conclusion that this must never happen again!”
    What lessons are being learnt?

  19. I thoroughly support Lynne Featherstone’s demand for be given to SCRs. It seems to me that inefficiency is the general defect vitiating any policy. Should someone be responsible for all visits to take place as planned, to keep note of all missed appointments and make new ones at once, to check that all communications are delivered punctually. The ‘casualness’ that Lynne Featherstone mentions extends throughout the civil service, hence loss of documents, internet communications etc. sense of urgency. Isabel de Madariaga

  20. A further argument for transparency in the publication of SCRs is the need to cut through the culture of affability that runs through the entire child safeguarding establishment, from local councils such as Haringey to the central government Safeguarding Unit, and embracing government and voluntary sector, the regulator (Ofsted) and the regulated. Sharon Shoesmith, in the Judicial Review of her dismissal, disclosed several emails and communications into the public domain showing the extent of this culture, from Sir Paul Ennals, chief executive of the National Children’s Bureau, Jeanette Pugh, director of the safeguarding group at the Department for Children, Schools and Families, Claire Kober of Haringey Labour Group, and Dr Ita O’Donovan of Haringey Council – all congratulating Ms Shoesmith for her command of the crisis the council faced this time last year. Moreover, Ofsted appears to have failed to disclose lost reports to the Review.

    It is not only the slovenly practices of ground level social workers that have contributed to the tragedy of Baby Peter, but the insidious culture of support at the very top – which has gone largely unremarked so far. All levels should be subject to greater transparency.