A little lad for whom it is all too late...

So, yet more discussions in the media over the last few days about the terrible death of little Peter, earlier known as ‘Baby P’.

Like many others, I have been following this story closely- and have posted thoughts on the issue several times. Earlier posts are here, here and here. This will be my last reflection…

So what has been going on?

It was the turn of the health authority to answer hard questions about its contacts with Peter and his mother. This from here.

Health workers missed dozens of opportunities to identify abuse being suffered by Baby P before his death because of “systemic failings” in the care given to the child, an official report has found.

The inquiry into NHS failings, conducted by the Care Quality Commission and published today, concludes that doctors and other health professionals had contact with the little boy 35 times but every chance to raise the alarm was missed.

Any one of these professionals could have picked up that he was suffering abuse if they had been “particularly vigilant” and gone “beyond what was required” by the system, the health regulator said.

The report talked about staff shortages, inadequate training, delays and poor communication. The General Medical Council has suspended from practice Dr al-Zayyat and Baby P’s family GP, Jerome Ikwueke, over their involvement in the case, but the Care Quality Commission was clear that no individual health workers should be singled out, as the problems were systematic. 5 Social work staff members have been sacked.

There are no surprises here. After every tragedy, and sadly Children die every week at the hands of their parents in this country, inquiries usually make similar points- communication, errors of judgment, poor training, staff shortages. These are not excuses- they are present realities of any beaurocratic response to complex human dysfunction.

Last week, Peter’s mother, her boyfriend were all sentenced. Entirely predictably, the Sun newspaper started a campaign to increase the sentences awarded. (The Sun had earlier campaigned for the sacking of social workers involved in the case, and claimed responsibility for their dismissal.)

And finally, Graham Badman, chair of Haringey local safeguarding children board (Sharon Shoesmith’s replacement) released details of a serious case review. This is the second such review, the first one concluding that there had been procedural failings and errors of judgment, but none on their own “were likely to have enabled further responses that might have prevented the outcome.”

Here is the Guardian’s take on the new report (from here)

The Badman review is clear that this was too generous a reading: Peter’s death “could and should have been prevented”. He could reasonably have been taken into care after the first serious incident, in December 2006, and on several occasions afterwards had professionals been more diligent.

The original report explains – but does not excuse – the failures to take Peter from his family in the context of the behaviour of his mother: she was frequently co-operative, with an open manner, and keen to please, so agencies built up a trust in her.

They saw Peter’s injuries as resulting from lack of parental supervision coupled with his observed tendency to “throw his body around and headbutt family members and physical objects.”

This perspective framed the way professionals viewed Peter’s subsequent injuries, the original report concluded. Wrong-footed by the mother, and seemingly never quite getting enough solid evidence to warrant a criminal charge or issue care proceedings, they effectively gave her the benefit of the doubt. The overwhelming sense of the first review is of well-meaning professionals struggling to bring a clear focus to an infernally complex, chaotic and constantly shifting situation.

Badman is scathing of this. He argues that social workers in particular were too timid. Professionals “over-identified with the parent”, and were even bullied by her.

While the original report gives no clear picture of the mother, Badman portrays her as an arch-manipulator, subverting the professionals, “a dominating and forceful personality”, eminently capable of intimidation.

In the report, there is a devastating sting in the tail. It remains to be seen whether there will yet have to be a public back lash against this- the usual corrective pendulum swing in the opposite direction…

Badman’s interpretation, fashioned with access to more information, is at times clear-sighted in spotting of unforgiveable errors, at others unforgiving of understandable human failings.

Professionals should be more interventionist: if they suspect abuse, they should act on it, even if they are proved to be mistaken. “Better that than the harm the child will experience.”

The removal of children from home, and reception into care has already increased in real terms by around one third. Each one of these actions is a human tragedy- characterised by damaged and broken people, holding opposing and contradictory views, and professionals acting in a context where information is incomplete, and finances are under great pressure.

So for those of you who will never have to encounter such incredibly difficult situations- know this. There will be more scandals. More children will die. There will be more outcry as children are removed on evidence that later turns out to be wrong.

And in the middle of all this will be a set of people who will be held accountable. They will almost certainly be social workers.

Who else?