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Government publishes Peter Connelly Serious Case Reviews

Peter’s ‘death could and should have been prevented’

The Government has published the two Serious Case Review reports relating to Peter Connelly.

The first SCerious Case Review was commissioned in August 2007 by Haringey Local Safeguarding Children Board (LSCB), under the chairmanship of Sharon Shoesmith, and the executive summary was published by the LSCB in November 2008. This SCR was evaluated as 'inadequate' by Ofsted.

In December 2008, the then Secretary of State for Children, Schools and Families directed the appointment of a new LSCB Chair, Graham Badman, and asked the Haringey LSCB to begin a new SCR on the case of Peter Connelly. This second SCR was evaluated as 'good' by Ofsted and the executive summary was published in May 2009.

Conclusions of the second SCR
The second SCR concludes that, for a case which reflected such highest level of concern, the interventions were: 

The SCR panel was of the view that all staff in every agency involved with Peter and his family were well motivated and concerned to play their part in safeguarding him and supporting Ms A to improve her parenting. They were deemed to be competent in their safeguarding and child protection roles as they understood them to be, based on their experience and qualifications. They had the appropriate qualifications and experience for their roles and were no less qualified and no less experienced than staff in similar roles in other places. However, in this case they did not exercise a strong enough sense of challenge when dealing with Ms A and their practice, both individually and collectively expressed as the culture of safeguarding and child protection at the time, was completely inadequate to meet the challenges presented by the case of Peter Connelly.

In this case the interventions were not sufficiently authoritative by any agency.
The Panel says that it is difficult to determine whether or not that quantum of resource should have been deployed differently. However, the Panel is clear from the detailed consideration of workload and deployment of frontline staff is that further resources in themselves would not have impacted on the outcome of this case.

The Panel conclude that Peter's horrifying death could and should have been prevented. If the principles and approaches described in this report had been applied by the four protecting professions, the situation would have been stopped in its tracks at the first serious incident. Peter deserved better from the services which were there to protect him, and they in turn deserved better than the ethos which influenced their work at the time.

Response of Haringey Council
Chair of Haringey Safeguarding Children's Board, Graham Badman said:

"The tragic death of Peter Connelly has quite properly caused a fundamental re-appraisal of child protection services in Haringey and throughout the country.  If Peter is to have a legacy, it is that other children are now safer as a consequence of the honest analysis of events that led to his death and the embedding in practice of the lessons learned.

"Services in Haringey have improved dramatically but the LSCB will continue to be vigilant in both auditing and seeking improvement in the management and conduct of all services charged with child protection.  The publication of the full Serious Case Review marks an end point but also demonstrates the integrity and willingness to change of all services that contributed."

Haringey's Cabinet Member for Children & Young People Cllr Lorna Reith said:

"We have accepted that things went badly wrong with our child protection services back in 2007 and have apologised unreservedly for our shortcomings and mistakes.  Baby Peter's death could and should have been prevented.

"Since publication of the serious case reviews, whose recommendations we have implemented in full, it has been our top priority to bring about substantial change and improvement to children's safeguarding in the borough. 

"The recent unannounced inspection by Ofsted – which took place in August and reported in September - was tangible proof that significant progress has been in made but it is our responsibility to remain vigilant in Baby Peter's memory and never stop improving."

Government's position on SCRs
The Coalition Government confirmed on 10 June 2010 its intention that the overview reports (together with the executive summary) of SCRs would be published, appropriately redacted and anonymised. Birmingham Safeguarding Children Board published the SCR overview report relating to Khyra Ishaq on 27 July 2010.

The SCR overview reports relating to Peter Connelly were written by independent authors commissioned by Haringey LSCB. The only editing undertaken by the Department prior to publication by the Department is the redaction of information that it is not appropriate to put into the public domain. An explanation of the redactions is set out in the beginning of each report.

Accessing the SCRs and other materials
The SCR overview reports for Peter Connelly are available for download: 

First Serious Case Review overview report relating to Peter Connelly dated November 2008. 
Second Serious Case Review overview report relating to Peter Connelly dated March 2009. 
The executive summary for the first Serious Case Review overview report dated November 2008 relating to Peter Connelly.
The executive summary for the second Serious Case Review overview report dated February 2009 relating to Peter Connelly.
A copy of the letter of 10 June 2010 sent to DCSs and LSCB chairs by Tim Loughton, Parliamentary Under-Secretary of State for Children and Families, to confirm new arrangements and amended guidance for publication of SCRs.