A spate of phone calls and texts from the media remind me that it is two years since Baby Peter was ‘allowed to die’. The anniversaries will come and go. The investigations, inspections and reports come and go. But what will really change?

The fear that haunts me is that the words are easy – ‘lessons must be learnt’ – but we heard that beating of the chest and wringing of hands post Victoria Climbie – but nothing much actually changed at Haringey Council. New processes were brought in post Lord Laming’s inquiry – but the culture of Haringey didn’t change one iota. It remained arrogant, unwilling to let in the light scrutiny – or even to be questioned. That defensiveness, secrecy and closing of ranks allowed a second tragedy of immense proportion to take place despite the promises that lessons would be learned.

What I think is that unless and until processes take place in a culture that is open, welcoming of questioning and where people do their own job to the highest standard possible (not relying on tick boxes but on conscience, good training and supervision) it could all happen again. I fear that some of the investigations and recommendations, followed by numerous action plans and inspections feel like lots is being done – but real change can only come from leadership at every level.

Sadly, secrecy prevails. The Government refuses to hold a public inquiry. The Government refuses to publish the (now two) Serious Case Reviews.

We still need that inquiry. Whilst Haringey, quite rightly, was held firmly in the spotlight of blame as the lead agency, the other agencies have had relatively scant focus. They have contributed their reports to the investigations – but the pressure is not so focused.

In terms of health – the managers at Great Ormond Street who refused to take the concerns of four paediatric consultants seriously (the four who signed a letter to the management flagging up the dangers for children because management were not listening) are still in place.

Ofsted, who inspected Haringey at the time of Baby Peter and gave them a three star rating which plummeted to one star post Baby Peter scandal, have got away virtually scot free.

The police, whose poor handovers and missing files led to the Crown Prosecution Service saying that had this been done properly they might have been able to bring an early conviction, are out of the limelight. And so on and so on.

Ed Balls says he doesn’t want to publish the Serious Case Review – even though this would allow professionals right across the country in all the agencies to witness the litany of failures, both personal and systemic – and so learn for their own services and their own work.

The shock of that document (which I am still forbidden to speak about – and I only saw the first one not the second one re-commissioned by Balls) is the casualness with which people did their jobs. To most people, if a child is on an at risk register – we would expect more rigour and absolute professionalism around such care. What we see is lots small failures: files lost, people not attending important meetings, missed appointments unchecked and unquestioned, inadequate or no handovers, etc etc etc.

How can lessons be learned when the details of what went wrong and how and why are kept secret?

So – I plough on trying to get things out in the open and done publicly. That is the first step only in my view. In Haringey, at least, the people have changed. The accountable people have actually lost their jobs – which at least sends the message that there is a point to the position – that there is responsibility and consequences. But as I say – in the end the two things I believe would offer better protection are a change in culture and the reinstatement of personal responsibility within any function – above and beyond putting a tick in a box.