Trusts have been urged to ensure they are meeting child protection standards in a report revealing “systemic failings” in the NHS’s treatment of Baby Peter.

The Care Quality Commission has today published a review of the care provided by the NHS organisations involved in the care of Baby Peter, who died aged 17 months in August 2007 after a lifetime of abuse.

Peter had at least 34 contacts with health professionals at services provided by Haringey primary care trust, North Middlesex University Hospital trust, Whittington Hospital trust and Great Ormond Street Hospital for Children trust.

Inspectors found a catalogue of failings including poor communication between health workers and agencies, a lack of awareness about child protection procedures, poor recruitment practices, staff shortages and governance failings.

CQC chief executive Ms Bower said: “This is a story about the failure of basic systems. 

“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.”

The trusts involved had made steps towards addressing the problems, she said. North Middlesex University Hospital trust and Great Ormond Street Hospital for Children trust have both posted apologies on their websites today.

Wider call

The report also makes a wider call for trusts to check they are properly safeguarding children in their care.

It notes that the boards of all four trusts declared themselves as complying with relevant core standards for three annual health checks.

The report states: “…regulators alone can never ensure that those who provide services on behalf of children always do so appropriately and safely.

“It is the responsibility of those who run the services to ensure that the right overall systems are in place and that they can check that these systems are working properly.”


NHS Confederation deputy policy director Jo Webber said leaders were central to improving child protection.

She said: “Good leadership will not only improve the flow of information and the effectiveness of joint-working between and within agencies but will also provide workers with the support they need to do their jobs better – particularly in terms of staffing, supervision and training.

“Allied to this however must be the fundamental understanding that child protection is everybody’s priority.”

Later this year, the CQC will publish a national review to see whether NHS trusts across England are meeting their obligations to safeguard children.