Poor management and staff supervision led to the death of 'Baby P', an official document has revealed.
The 17-month-old boy died in August after being repeatedly abused by his mother and stepfather in a council flat in Haringey, North London. He was visited 60 times by professionals during the course of his short life, with one paediatrician examining him just two days before he died and failing to notice a broken back and ribs.
A review commissioned by Haringey Council immediately after the death, submitted to the Department for Children, Schools and Families yesterday, revealed the serious people management failings that ultimately led to the failure to protect Baby P.
Ed Balls, the children's secretary, said in a statement: "The review's findings indicate a number of failings of practice and management by the agencies involved."
The report found clear evidence that each local agency involved with the case had failed to adhere to the procedures for the proper management of child protection cases.
In particular: there was evidence of poor quality practice, management and supervision of staff in all agencies; and health professionals appear to have failed to follow the appropriate procedures when there was evidence of a child having suffered non-accidental injuries.
Balls added: "Clearly, such findings in an individual case raise serious concerns about the wider systems and management of services for safeguarding children in Haringey."
Ofsted, which regulates children's services, the Commission for Healthcare Audit and Inspection and the Chief Inspector of Constabulary have been ordered to carry out a further review of safeguarding and promoting the welfare of children in Haringey.
Balls said the review needed to scrutinise management practices, including "the quality of practice and decision making by front line workers".
Jane Collins, chief executive of Great Ormond Street Hospital which provided paediatric services to the child, said: "It is clear that more should have been done when the child was seen by a paediatrician two days before the child died. The review process is important in understanding what happened and how procedures can be strengthened for the future. Where we have ne