NHS blamed for Baby Peter failings
Updated on 13 May 2009
Systemic failings by the NHS contributed to Baby Peter's death, according to a report from health watchdogs.
The Care Quality Commission said doctors and other health workers had contact with the little boy 35 times in his short life but every opportunity to raise the alarm and save him 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", the report said.
The commission examined the actions of four NHS trusts in London involved in the care of Baby P, who can now be named as Peter, before his death in August 2007 aged just 17 months.
Investigators found a "catalogue of errors", including chronic staff shortages, inadequate training, long delays in seeing the child, and poor communication between health workers, police and social services.
They highlighted a series of failings when consultant paediatrician Dr Sabah Al-Zayyat saw Baby P at St Ann's Hospital in Tottenham, north London, two days before he died.
Dr Al-Zayyat decided she could not carry out a full check-up because the little boy was "miserable and cranky" and did not spot that he had serious injuries, probably including a broken back and fractured ribs.
She was one of only two consultants at the specialist children's clinic at St Ann's Hospital, when there should have been four.
On an earlier occasion, in April 2007, Baby P was discharged from North Middlesex University Hospital in Edmonton, north London, without a formal meeting to discuss concerns about possible abuse - contrary to standard procedures.
Sue Eardley, the Care Quality Commission's head of children's strategy and safeguarding, said it was a problem of system failures rather than "individual culpability" by the health workers who saw Baby P.
Commission chief executive Cynthia Bower said it was vital that lessons from the case were learnt across the country as well as in north London.
She said: "There were clear reasons to have concern for this child but the response was simply not fast enough or smart enough."
The four trusts covered by the report are: North Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust, Great Ormond Street Hospital for Children NHS Trust and Whittington Hospital NHS Trust.
The General Medical Council has already suspended from practice Dr Al-Zayyat and Baby P's family GP, Dr Jerome Ikwueke, over their involvement in the case.
Baby P was on the at-risk register when he was found dead in his blood-spattered cot in Haringey, north London, on August 3, 2007.
He had suffered 50 injuries despite receiving 60 visits from social workers, doctors and police over the final eight months of his life.
Last year his mother, her boyfriend and their lodger were convicted at the Old Bailey of causing or allowing his death. Earlier this month the boyfriend was also found guilty of raping a two-year-old girl.
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