Michael Gove is to be commended for publishing the two Serious Case Reviews (SCR) on the tragic events leading up to the death of Peter Connelly (Baby P). Labour always refused to do so – but if that somewhat overused phrase ‘lessons must be learned’ is to mean anything – then publishing SCRs is a real step in the right direction.
Finally, we can actually see what was in the first SCR – and then see what was in the second SCR commissioned by Ed Balls because he believed the first one was ‘inadequate’.
Having read both – twice – I think on closer inspection they raise more questions than they answer.
At the end of the trial of Baby Peter’s mother, boyfriend and lodger, together with about four others, I was allowed to read the first SCR under lock and key and with the proviso that I never revealed what was in it. So all I ever said about it was that people would be shocked to find such a litany of casualness by every individual and every agency involved in child protection.
And indeed, that was the verdict yesterday by the media and commentators. The extraordinary thing is that when there is a child protection plan in place as there was with Baby Peter – given that child has been assessed as ‘at risk’ we (the people) would expect those charged with the child’s safety to be rigorous in their attention to detail. Instead we find a litany of missed appointments, no follow-ups, files lost, handovers not done, meetings not attended. It is genuinely an appalling litany of casualness.
But all of this was quite clear in the first SCR. It wasn’t well written or well-analysed – but seemingly the information was there even if in a somewhat rambling form. So – why did Ed Balls commission a second SCR?
Looking at the second SCR – it doesn’t really answer that question. Yes – it is better written, better ordered and the analysis is sharper – but it doesn’t seem to add anything new. In fact – it addresses far less – and astonishingly seems to airbrush out the child health protection agencies. There doesn’t seem to be a mention in the body of the text (except introductory) of Haringey PCT, St Ann’s or Great Ormond Street Hospital (GOSH). Yes – there is a chronology of events – that describes going to doctors, visits to hospitals – individual’s failings on health – but nothing about the management of those services at all.
Given that I have been banging on about the child health protection part in all of this on the floor of the Chamber myself, on this blog, in articles and I even got Norman Lamb (at that point LibDem Shadow Health Secretary) to raise it – I find the omission extremely surprising.
I first raised the alarm on the health issue because I couldn’t understand why there was a locum in the first place – the locum who turned out to be the doctor who didn’t recognise the injuries of Baby Peter – just before he died. It turned out that there was a locum because the department was understaffed drastically because two senior paediatricians had resigned; one was on sick leave and one on special leave.
It also turned out that four senior paediatric consultants had written to the management of GOSH to raise the alarm on unsafe procedures and clinicians’ concerns not being listened to.
There’s more – but the essential issue – is why are all the issues around management failure in the child health protection team not included in the second SCR? They are in the first one. There are lots of recommendations in the first SCR for GOSH and Haringey PCT. Why are there none in the second? It’s as if GOSH and Haringey PCT have been spirited away.
Also, most strangely, the second SCR focuses almost entirely on Haringey Children’s Services – and whilst yes – they were undoubtedly the lead agency and deserved the priority scrutiny – the child protection health arrangements were a whisker behind. Was the second SCR directed by someone to focus attention more on one agency than another involved in the case? If so – why?
I will be interested to see what experts, professionals and commentators think after they have had time to read the reports fully. The day of publication was more to do with the shock of seeing the litany of failure that led to Peter Connelly’s death. In the cold light of day – with more time to read both SCRs together – more in depth analysis will be helpful.