Care Quality Commission publishes report on the NHS care of Baby Peter

Published: 13 May 2009 Page last updated: 12 May 2022

13 May 2009

  • Robust improvements already made but more necessary
  • National review of NHS safeguarding of children underway

The Care Quality Commission (CQC) today (Wednesday) publishes a report showing systemic failings in the healthcare provided by NHS trusts to Baby Peter.

The report raises questions about how NHS trusts assure themselves they are meeting important standards for safeguarding children.

Excluding his birth, Peter had 34 contacts with health professionals at North Middlesex University Hospital NHS Trust and Haringey Teaching Primary Care Trust. Both trusts commission paediatric services provided by Great Ormond Street Hospital for Children NHS Trust (GOSH).

The main focus of the report is on these three trusts as they provided the majority of Peter's NHS care. He also attended on one occasion the Whittington Hospital NHS Trust, so the report looks at child protection procedures in place there as well.

The report makes clear that since Peter's death the trusts involved have made progress in addressing gaps in child protection procedures.

It highlights improvements including measures to ensure that medical staff have a child's background medical notes when treating or assessing them. Steps have also been taken to ensure that a social worker is present at child protection assessments.

But the report says more work still needs to be done in areas like: ensuring sufficient staffing levels; improving attendance of healthcare staff at child protection case conferences; and addressing communication problems, particularly when making referrals.

This is the first of two reports that CQC will be publishing in relation to child protection in the NHS. Both were requested by Health Secretary Alan Johnson after publication last December of a joint area review of safeguarding in Haringey, which found that agencies were not working effectively together.

This first one brings together for the first time comprehensive evidence on the healthcare provided to Peter including: information from medical notes; the joint area review of safeguarding in Haringey (carried out by the Healthcare Commission, Ofsted and HM Inspector of Constabulary); and Haringey council's serious case review report relating to Peter's care.

In the second report, due out this summer, the CQC will report on findings of a national review of NHS arrangements for the safeguarding of children, which is already underway. The review was triggered by concerns that NHS trusts were not clear on how to ensure safeguarding systems are robust.

Speaking about the NHS trusts involved in the Baby Peter case, CQC Chief Executive Cynthia Bower said:

"This is a story about 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. The NHS must accept its share of the responsibility.

"The process was too slow. Professionals were not armed with information that might have set alarm bells ringing. Staffing levels were not adequate and the right training was not universally in place. Social care and healthcare were not working together as they should. Concerns were not properly identified, heard or acted upon.

"The NHS trusts involved have already responded robustly and made clear improvements. But there remain significant further steps that must be taken. We must get to a position where we can say everything possible is being done to prevent a recurrence."

Ms Bower added:

"It is imperative to ensure lessons are learnt across the country, as well as in north London. We are concerned that NHS trusts don't always know whether they are doing the right things to safeguard children. Our national review will check what information trust boards use to assure themselves they are getting it right. We will not hesitate to use our powers if we find trusts are not doing enough to ensure appropriate safeguarding procedures are in place."


For further information please contact Emma Reynolds in the CQC press office on 0207 448 9040 or out of hours on 07917 232 143.

Notes to editors

Issues from the report

The Commission's report identifies the following systemic failings:

  • Poor communication between health professionals and across agencies, such as social services and the police, meant that urgent action to protect Peter was not taken. For example: the consultant who saw Peter two days before his death did not have any contact with his social worker; health professionals did not always attend child protection conferences to discuss Peter's case; poor completion of child protection forms by some health professionals meant that social care staff were not always aware of their concerns.
  • Staff caring for Peter did not always follow child protection procedures. For example: when he was discharged from North Middlesex Hospital in April 2007, no formal discussion was held to escalate concerns, despite him being on the child protection register; there was an absence of bone and skeletal surveys which could have provided a clearer picture of the nature of injuries; staff use of parallel growth charts in the monitoring of Peter's development was not routinely documented, despite ongoing developmental concerns.
  • Poor recruitment practices and lack of specific training meant that some staff were inexperienced in child protection. Some staff appointed by GOSH to posts at Haringey PCT were appointed despite not having the required experience in child protection that would be expected for certain posts. They also did not receive appropriate training to develop this knowledge following their appointment.
  • Shortages in staffing at St Ann's Hospital, where Peter had his paediatric assessment, led to delays in seeing children. This included shortages in consultants, nurses and administrative staff. At the time of Peter's assessment at St Ann's Hospital on 1 August 2007, there should have been four consultants in post but there were only two.
  • There were failings in governance systems in three of the trusts concerned. Healthcare professionals at North Middlesex Hospital were not always clear on who was responsible for following up child protection referrals, for example they sometimes relied on social services staff to initiate communication after faxing a referral through. Staff also reported a lack of safeguarding supervision which would have helped ensure that they were clear about their roles and responsibilities in relation to safeguarding children.

Action taken by trusts after Baby Peter's death

Staff from the Care Quality Commission's predecessor, the Healthcare Commission, visited the trusts to check what actions had been taken since the failings were identified. They also met with key staff to assess how effective the safeguarding processes are at each trust.

They found that since the death of Peter the trusts had:

  • Increased the number of consultants at St Ann's Hospital from two to four, including a named doctor in child protection.
  • Made sure background notes are always available prior to an assessment at St Ann's Hospital (commissioned by Haringey PCT).
  • Ensured that when a child is referred for a child protection assessment a social worker is present. Although the Commission noted that it was frequently not the child's allocated social worker and therefore often has limited knowledge of the child.
  • Updated the shared policy for prioritising and progressing referrals quickly to avoid delays.
  • Updated staff training to make sure it complies with safeguarding guidance.
  • Established a jointly managed paediatric service at North Middlesex Hospital NHS Trust and Haringey Child Health Services to encourage joint working and sharing of information.

Remaining shortfalls and action being taken

The report also makes recommendations to address remaining shortfalls. Although the publication of the report was delayed to prevent any prejudicial effect it may have had on a related court case, the report findings and recommendations were shared with the four trusts in March so they could begin to take action in the following areas:

  • Some staff at North Middlesex Hospital NHS Trust were still not clear about who is responsible for following up child protection referrals to social services. The report recommended all four trusts should establish clear communication and working arrangements with social services departments. In particular they should ensure contact between agencies is established immediately once a referral is made. GOSH and North Middlesex University Hospital have since developed a cross-agency pilot scheme for new referral systems, but more work is needed to develop and roll out an effective permanent system.
  • The attendance of healthcare professionals from North Middlesex University Hospital and Haringey PCT at child protection case conferences was not good enough. Some staff at Haringey PCT also said they were not currently receiving any form of safeguarding supervision from a designated or named doctor for safeguarding. The report recommended that boards of all four trusts must assure themselves that these issues are addressed. The trusts have started to address these areas, with many staff now receiving supervision by a designated doctor or nurse at North Middlesex University Hospital, and provision is in place at Whittington Hospital to ensure there is always a member of staff present at a case conference. Trusts need to maintain their focus on these areas as there is still work to do.
  • The A&E service for children at North Middlesex Hospital NHS Trust was perceived by some staff to be potentially vulnerable as there was no paediatric department after 7pm. North Middlesex University Hospital paediatric A&E is now open 24 hours a day, seven days a week. There remains only one consultant on call for the whole paediatric service after 5pm and at weekends, but there is an adequate complement of other appropriate staff, such as children's nurses and registrars to run the service.
  • The report recommended Haringey PCT and North Middlesex Hospital must work with GOSH to ensure they have a sufficient number of appropriately qualified paediatric staff. All four trusts should also ensure their staff are clear about child protection procedures and receive safeguarding training to an appropriate level. The trusts have since begun to address shortfalls in staff training where necessary, but more can be done to ensure more people are trained to an appropriate standard.
  • Haringey PCT is still under-staffed in terms of health visitors, school nurses and support staff. In addition, the report recommended that GOSH must review the consultant cover at St Ann's Hospital to make sure it is adequate. GOSH has made efforts to address this and recognises the need to recruit an academic paediatric consultant. However, the service remains understaffed. GOSH has moved child protection assessments from St Ann's to North Middlesex where there is better provision of paediatric services.

The trusts involved in the review were required to produce action plans to address the remaining shortfalls. The CQC says although the trusts have already made progress against the report's recommendations, there is still some way to go. It will work with NHS London, the strategic health authority, to monitor trusts' progress.

In order to ensure progress continues, the CQC will be requesting the trusts to provide evidence of implementing the relevant recommendations in six months time. The follow-up may also involve revisiting the four trusts in order to observe how new procedures and policies are working in practice.

CQC'S national review of safeguarding

As part of its national review of NHS safeguarding arrangements, the CQC has asked all trusts in England to describe what arrangements they have in place to ensure they have effective child protection systems, in line with government core standards and national statutory guidance.

The CQC is concerned that three of the NHS organisations involved in the care of Baby Peter stated that they fully complied with standards for protecting children when this was clearly not the case. It may be that trusts are insufficiently rigorous about ensuring their safeguarding practices are robust and may not be collecting sufficient information to support their declarations.

The CQC's review will look at governance, training and staffing, as well as how individual cases are handled. It will also look at how healthcare organisations work in partnership with others.

About the CQC: Snippet for press releases

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.