A Review On The Tragic Case Of Baby P

In this assignment, I will talk about the baby P case. A distressing case of a 17 month old baby that was viciously beaten on many occasions as social workers, doctors and the police stepped back and watched as the young baby who was supposedly a child in protection died in a blood-spattered cot in 2007 spending most of his life being used as a punching bag. (Mail Online: 2008)

I will also discuss “what went wrong” the failures that let this case down and some recommendations for what have been changed since to prevent this situation from happening again.

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Peter Connolly was born on the 1st of March 2006; he was a happy healthy baby boy. He attended regular check -ups in the hospital, showing no signs of major concerns. It was only 6 months after, on the 19th of September issues arose on baby Ps health when his mother brought the child to see the GP confirming that the child bruised easily and she was worried that claims would be made accusing her. The child was later brought back to hospital for check-ups presenting more and more bruising as the visits went on. In December 2006, doctors described these injuries as “non accidental” and grew increasing alarmed of the welfare of the child. (Baby P and the Care Quality Commission Report: 2009)

At this point baby Ps mother was arrested on suspicion of assault and baby P was handed over to social services in care of Haringey’s child protection register. (Mail Online: 2008) It was reported that baby Ps mother took part in a parenting centre. (Baby P and the Care Quality Commission Report: 2009)

26th January 2007: the child was handed back to his mother, after the case proved inconclusive in court, against police advice. (Mail Online: 2008) During a visit in March, Maria Ward, Case worker, became aware of a mark on Baby Ps face claiming that he “bruised easily” from a fall. The doctors verified this claim, ruling out the theory, unfortunately, this information was accessed by police and social workers after the child’s death.

9th April 2007: Baby P was admitted to A&E with injuries sustained to the head. He was later emitted from hospital without any discharge meeting and hands back to his mother without any worries by case workers. (Baby P and the Care Quality Commission Report: 2009)

After missing appointments with health visitor, Paulette Thomas, Baby P’s mother was sent an appointment by child protection for a check up. During this check-up bruises were found on the child and his mother was arrested for the second time on suspicion of assault. Baby Ps mother was later released from Primary Mental Health Service and again was handed her baby boy. Cross agency meeting were called but the Haringey’s lawyers insisted there was a lack of information for care proceedings to take place. (Mail Online: 2008)

It was heard in court that on his final days, Baby P was smeared in chocolate and nappy cream to hide bruises or injuries from Maria Ward on her visit later on that day. It also heard that before baby Ps death he was scheduled to be assessed by Sabah-Al-Zayyat, a paediatrician. (Mail Online: 2008) “Despite Baby P’s repeated cries of pain, the consultant missed both his broken back and ribs” (Times online: 2008) She claimed she was unable to assess the child because he was miserable and cranky. (A short life of misery and pain: 2008)

The trail heard that Baby P spent his last weekend with his natural father, where he noticed that the child’s head had been shaved and that he was missing a finger nail. They also heard that on his final night Baby P received a harmful whack, knocking out a tooth, which was later found in his stomach. After all his suffering, “He was found dead in his blood-spattered cot the next morning and police summoned to the Middlesex Hospital were struck by his mothers lack of emotion” Even after her child’s death she was more worried about finding her cigarettes before she left the house. She and her lover (who claimed to be toughing up the child for when he was older) were arrested without any delay. (Mail Online: 2008)

What went wrong?

Throughout this case there are many key aspects missing. A big aspect of the failure in this case was the lack of communication and of the team work and collaboration. “A team of individuals, with vary backgrounds, perspectives, skills and training, who work together towards the common goal of delivering a health or social care service”. (Dalikeni C: 2010)

There was very little team work and sharing information between the services in this case. Services included in this case were the police, social workers, case workers and doctors. Information collected throughout this case by the individual services was kept to themselves and advice given by the various services was ignored. E.g. 19th September when Baby P first starting showing signs of bruising and his mother claimed that the child bruised easily, no further investigation into the concerns of the child were taken. This shows a lack of interest on behalf of the doctors involved in this case. Again in December when doctors proved that the child’s bruising was “non accidental” and his mother was arrested, he was later handed back to her by social services in Haringey’s child protection against the advice of the police. This was another failure through lack of communication between police and social services. No further check-ups or visits took place. (Baby P and the Care Quality Commission Report: 2009)

In March, when Miss Ward became aware of marks during her visit she dismissed them as a fall, this information was ruled out and the report reached the police and social services after his death, this was 5 months after the claim had been reported. This proved that Miss Ward under analysed this case. This again was another communication failure between the services, this was through there inappropriate systems for communication or “where staff did not adhere to processes for their particular organisations” (Baby P and the Care Quality Commission Report: 2009)

It was reported that when Baby P had been admitted to A&E he was handed back to his mother without any discharge meeting taken place. This shows again the lack of awareness shown by professionals and also the lack of communication between the professionals themselves in the same services. In this case guidance was ignored when it was clear that the child had been sent to hospital by child protection due to concerns of the child’s welfare, no meeting or discussion was taken place prior the child’s discharge. In these cases a formal strategy should have taken place in the interest of the child. (Baby P and the Care Quality Commission Report: 2009)

Team work is set in place for many different reasons e.g. joint responsibility, constant interaction with peers, support, different roles and relationships with service users and because most of the work in the fields of the health department, social work, police etc is more appropriate done as part of a team. This can only ever be effective if there is open communication, clarity in task, interagency collaboration etc, yet through this case many of these key points are missing. (C. Dalikeni: 2010)

After the tragic death of Victoria Climbe in 2000, Haringey social services were critized over their failures to save her from child abuse, 7 years later they yet again were in the spot light for failing another child. (A short life of pain and misery: 2008) Although he was put in child protection Baby P died 8 months after. Even after his mother was arrested twice the social services still handed him back to his mother without any worries of his welfare or any acknowledgement of advice suggested by police.( Mail Online: 2008)

The ladder of collaboration was taken into consideration when it came to agencies in this case. Step 7: Different agencies are invited to each other’s meetings this would have helped all agencies stick together with the same information and no boundaries would be broken and everyone would be clear on their position and what they were assigned to do. (The Reality of Collaborative working: Pg 247)

A lack of details on the background of the case was taken, this caused a set back on the information getting appropriately to the different agencies. Child protection conferences are an idol way of professionals in this case of getting and sharing useful information for what was in the best interest of the child. It was evident that this was not the case in this situation, this is all shown through the lack of information on the case and it is also apparent that these professionals often didn’t even show up at these meetings.(Baby P and the Care Quality Commission Report: 2009)

Another issue that caused failures in this case was that a full background history of the child was not in the hospital on any occasion he was taken into hospital for his check-ups. (Baby P and the Care Quality Commission Report: 2009) Stage 2: Ladder of collaboration would have been useful here , while the child was being checked, another doctor or member of the child protection services could have taken an account of the child’s injuries or any concerns (The Reality of collaborative working: Pg 247) This would show an indication of interagency collaboration through the reduction of overlapping on information already taken, Providing a share in the responsibilities and reduction of stress of members of the individual agencies. (Macklin 1991, Harris et al 1995)

” Haringey’s decision to return baby P to his mother effectively handed the child “a death sentence” according to Mor Dioum of the Victoria Climbe Foundation” (Mail Online: 2008)

When Miss Ward was o her home visit and seen that Baby P was covered in chocolate and nappy cream, instead of dismissing this, she should have asked for the child to be cleaned up properly before checking him. This would have helped her notice any marks or injuries the child may have had and were being hidden from her from the abuser.(Baby P Better Protection for vulnerable children & Practical Recommendations: 2008)

A big part of the failures in this case was the handing back of Baby P to his mother against any advice from the police. Social workers should have taken into consideration the advice and should not have been over ruled. After signs of abuse the child should be taken from the family and put into care to avoid any other risks to his/her health and welfare.(Baby P Better Protection for Vulnerable children & Practical Recommendations: 2008)

Unannounced/Surprise visits should be put in place. These check-ups would be idol for abusers that try hiding any signs of danger or injury on a child. This gives the social worker a better idea of the background of what the child is really going through. This also stops any time for “explanations”/excuses that the abusers would have to make up to cover themselves for any injuries the child may have.(Baby P Better Protection for vulnerable children &Practical Recommendations: 2008)

In this case social workers were more worried about keeping this family together instead of the welfare of the child. This should not be first priority, in the interest of the child is taken into consideration the child should be removed from the family if any risks should become a concern. Removing the child from the family in any abuse case is an idol way for the child to be safe and avoid any other injuries or health problems for the child. (Baby P Better Protection for vulnerable children & Practical Recommendations: 2008)

These are only some of many recommendations that should be available to the social services, medical professionals and also the police. This would help insure that children all around the world are safe and free from child abuse.


On conclusion to my easy, we have seen many tragic occasions of child abuse and how without any proper care this child was taken from the world earlier than he should have been. Hopefully now the social services, police and doctors can introduce more strict regulations to prevent any more situations more/less horrific as this one.

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