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Page last updated at 11:16 GMT, Wednesday, 27 October 2010 12:16 UK
Baby P: Where does the buck finally stop?

Tim Donovan
BBC London's Political Editor

Peter Connelly
Peter Connelly died in August 2007 after suffering months of abuse

With the publication of the two serious case reviews into Peter Connelly's death, people can now read for themselves what a complex story this was.

The toddler had many contacts with many different agencies over his short life and self-evidently, given the outcome, their efforts failed.

But putting your finger on the fundamental underlying flaws is not as easy as you might think. And trying to establish a kind of hierarchy of blame is impossible, not to say simplistic.

Was it the doctors who failed to act on what they saw? Or the social workers who didn't stand back a moment and notice how things were deteriorating? Or the police who didn't regard this case as quite serious enough for them? Or the council lawyers who in the end weren't convinced it was one for care proceedings?

'Inadequate'

The two reports are tableaux from which anyone can cherry-pick individual failures and missed interventions which they think important depending on their own instincts and prejudices. But it's fruitless.

Some say accountability should have passed up the line, from the social worker to the team leader, from the children's director to the council leader. From the chief executive to…...Ed Balls.
Tim Donovan

Hindsight is everything and it's impossible to make a reliable judgement without knowing how it looked close-up, on the ground, to those individuals whose job was to treat, protect and care for Peter.

It's being claimed that the first review was 'inadequate' and the second told it straight.

In fact the first has more detail and more balance. The second is clearer in its judgements. And nice clean attributions of responsibility are what politicians like.

The second (and thus official) serious case review says Peter's abuse should have been stopped in its tracks at the first sign of trouble - a very particular point of view.

Its assessment is front-loaded, aiming disapproval at the decision not to pursue care proceedings when suspicions of ill-treatment first emerged.

It is curiously determined to focus on the failings of social workers. This is a flaw given the huge involvement of the health service and how much Peter's mother spent with her boy in medical settings.

Media storm

Excluding the details of an independent report into the locum - Dr Sabah Al-Zayyat - and the clinic where she worked is a startling omission according to Home Office minister and local MP Lynne Featherstone.

The first review gives a more thorough and less emotive account of everyone's actions.

It has been condemned as too soft and too reasonable. It was produced in a state of anxiety ahead of a likely media storm and amidst great acrimony between agencies, particularly Sharon Shoesmith and the senior health managers.

When it came to the second review, to an extent the pressure was off, and the criminal convictions had happened along with the sackings.

A narrative had already been placed in the public's mind. And the senior officials on the review panel from the health service, hospitals and the police could relax.

It is hard not to question how much the second case review - done at huge public expense - was needed.

However this case might have been portrayed, the evidence doesn't support a simple narrative of relentless abuse of a child over several months.

Complex pattern

Abuse to which the doctors, health visitors, social workers, police and others turned a blind eye, allowing events to hurtle to their inevitable, logical conclusion.

It was a much more complex pattern. Over the six months after Peter was placed on the child protection register, there were plenty of positive observations of the toddler with his mother.

When you read about Peter's admission to hospital in April and June with questionable bruising it's easy to jump to conclusions.

But on both these occasions doctors - the only ones able to do the tests and judge the physical signs - were not sufficiently worried to kick up a fuss.

The problem for all the professionals involved was less turning a blind eye than interpreting what was before their eyes.

It began as a perception that this was nothing too out of the ordinary. Yes, neglect, knocks, scrapes and poor parenting, but that could be managed.

And that perception didn't change fast enough when the evidence itself started changing.

Dramatic changes

It was about a month before his death that things did alter significantly, with increasing chaos descending on Peter's home. Tracey Connelly's boyfriend Stephen Barker was by then staying there much of the time.

But as an Old Bailey judge recognised after the criminal proceedings, it was the arrival of Stephen's brother Jason and his 15-year-old girlfriend which dramatically changed the dynamic.

It was reflected clearly in Peter's rapid physical deterioration. He lost weight and infections to his ear and scalp persisted despite medication. Doctors, health visitors and social workers all, between them, saw him frequently but no-one pieced it together.

His GP found him in a 'sorry state' but thought others would sort it. The consultant sent him home two days before he died.

But the wider lesson learned from all this is how hard it is to learn lessons in cases with such a high media profile and public interest.

Damage limitation

Serious case reviews are not a court of inquiry but their findings end up in the court of public opinion, certainly now the new government has decided to publish in full.

The more toxic the story - and this cannot always be anticipated - the more defensive the agencies are prone to be, withholding information and intent on limiting reputational damage.

Experts are right to be looking at new ways of doing this.

And what about the politicians?

Now in government the Conservatives are saying they don't want to be in the 'blame-game'

But it was David Cameron - then leader of the Opposition - who unleashed much of the turmoil over this case when he attacked Gordon Brown in Parliament, feeding the appetite of the tabloids, and making it a test of political credibility.

Malaise

With Ed Balls, then Children's Secretary, on the ropes, the social workers didn't have a prayer.

But was his training of fire on Haringey children's services department a pre-emptive strike to prevent what were clearly inter-agency problems in this case being held up as reflecting a deeper malaise throughout the child protection world?

Wasn't this a huge threat to the image of progress made since Victoria Climbie?

But if the failings in child protection here were across all agencies - systemic and reflecting a culture of poor management and practice at the frontline - then one thing arguably should have followed.

Some say accountability should have passed up the line, from the social worker to the team leader, from the children's director to the council leader. From the chief executive to…...Ed Balls.




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