The inquiry, conducted by the Care Quality Commission, revealed “a catalogue of errors” led NHS workers to miss dozens of opportunities to identify the abuse the chid was suffering.
The commission’s report investigated the actions of the four trusts involved in the scandal: North Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust, Great Ormond Street Hospital for Children NHS Trust and Whittington Hospital NHS Trust. Staff were found to have had contact with Baby P on 35 separate occasions, but still the abuse was missed.
Cynthia Bower, the commission’s chief executive, said: “There were clear reasons to have concern for this child, but the response was simply not fast enough or smart enough.
“The NHS must accept its share of the responsibility. Professionals were not armed with information that might have set alarm bells ringing. Staffing levels were not adequate and the right training was not universally in place. Social care and healthcare were not working together as they should.”
Sue Eardley, head of children’s strategy and safeguarding at the commission, added the problem was one of system failures rather than “individual culpability” by the health workers.
The NHS trusts investigated in the report have apologised for their failings and said they had taken steps to address them.
The commission’s findings were sent to the trusts in question in March and action plans have already been produced.
Health secretary Alan Johnson added: “These failures are unacceptable. The protection of vulnerable children requires the very highest levels of performance. We must do all we can to learn the lessons of this appalling case.”
The commission is now undertaking a review of all NHS trusts in England to check they are doing enough to protect vulnerable children. The review will be published in July.