The death of Baby P has been a stark wake-up call for trusts - both in terms of whether children in their care are safe and whether staff on the front line are properly supported. Charlotte Santry reports
A child abuse case described as one of the saddest and most shocking in recent history has sparked an investigation into whether NHS trusts are protecting children in their care.
Failings in the run-up to Baby P's death in the London borough of Haringey last August have been deemed so serious that health secretary Alan Johnson has instructed the Healthcare Commission to check whether trusts in England are meeting their duties to safeguard children.
Baby P died aged 17 months after a lifetime of brutal treatment that left him covered in bruises and scabs, with eight broken ribs, a broken back and missing the top of a finger. He suffered more than 50 injuries during an eight-month period in which he was seen 60 times by social workers and health professionals.
Lessons to learn
In addition to the distress anyone hearing the story will have experienced, NHS managers will be feeling jumpy at the thought of their organisations being exposed as failing in this hugely sensitive area.
Salisbury foundation trust chief executive Matthew Kershaw says it would be "foolhardy" to be complacent.
"As a chief executive you're the accountable officer. I'd feel it very dearly if it was an issue for this organisation," he says. "Whenever you get a case like this you step back and look at it to ensure, if there are any lessons, we're learning them."
He has already asked his safeguarding children nurse to ensure the trust's child protection processes are in place, in light of the Baby P findings, and to see if any improvements can be made.
Mr Kershaw's trust was rated weak for its overall standard of care for children in a Healthcare Commission report last year. The review, Improving Services for Children in Hospital, was intended as a "wake-up call for trust boards". It found child protection was a major risk in hospitals and more than half of services used by children did not meet necessary training standards.
Some boards did not see children's care as a matter for the trust as a whole, instead leaving it to paediatric departments. Following the assessment, Salisbury has put extra investment into training and is closely monitoring levels of uptake. But Mr Kershaw is concerned at the impact yet another high profile tragedy will have on staff morale and recruitment.
Calls for the scalps of Haringey council leaders have already been obeyed, and the doctor who allegedly put Baby P's cries down to "crankiness" has been publicly castigated.
"This case has brought a lot of things to light and raised [issues] in certain ways in the media," says Mr Kershaw. "If you're a student or graduate and are making a decision about becoming a social worker or health visitor, are you going to put yourself forward for child protection work?
"That's where there could be a real danger. These are sensitive cases, but we have to remember we need people to do these jobs."
Health visitors already face heavy workloads, with many responsible for hundreds of children, and threats of job cuts are being reported regularly by trade union Unite.
A quarter of health visitors surveyed in September by the Community Practitioners' and Health Visitors' Association, part of Unite, felt it was likely their NHS organisation would face a case like Victoria Climbié, the eight-year-old tortured to death by her carers eight years ago - also in Haringey.
One way in which commissioners can support frontline workers is to evaluate teams' skill-mixes, says Jane Lunt, Halton and St Helens primary care trust's operational director for children and family health commissioning.
"It's not just about more health visitors but looking at teams and how they're deployed," she says. "For example, most health visiting services have some responsibility for child immunisation but that can be done by staff nurses. We want health visitors to concentrate on the tough stuff."
The PCT is also reviewing who is being referred to social care and what happens when they get there, to understand the movement of children through different agencies.
But many commissioners have much to learn about child protection, the Royal College of Paediatrics and Child Health fears.
College child protection officer Rosalyn Proops says: "PCTs need to be better informed and more rigorous. At the moment we have some relatively isolated process measures. The health service has been driven by waiting times and performance measures that are more appropriate to surgical events."
As well as better data, she says, clinicians need to be allocated more time and resources for child protection work and training.
Her criticism of the way systems are measured will resonate with those asking why the four trusts involved in the Baby P tragedy were able to state compliance with core standards relating to child protection.
The standards cover areas such as:
whether trusts have a named doctor and nurse responsible for safeguarding children;
whether staff have received relevant training;
whether processes are being reviewed internally.
But these are treated by trusts as a mere checklist, according to Dr Proops. "The real questions are, is it clear what these named professionals' roles are and do they have the time to undertake them, how are governance arrangements put in place and how is learning demonstrated?"
Sue Eardley, Healthcare Commission head of children's strategy and safeguarding, denies there is a problem with the standards against which the commission assesses trusts in the annual health check, but says trusts are not always sure how to measure themselves.
"We're not saying boards are gaming, we need to help boards with assessing themselves against the standards."
The commission is expected to publish its review into safeguarding children by February.
It has already identified four areas it will particularly focus on:
communication between healthcare professionals and agencies;
awareness of healthcare procedures for child protection;
recruitment and training;
levels of staffing.
However, it is also likely to draw on the joint area review into Haringey children's services, published last week.
This highlighted many problems with local NHS services, such as files being poorly organised, illegible and even inaccurate. There were inconsistencies in the thresholds used for referral to social services and the quality of health assessments was poor.
Children admitted to accident and emergency services were not always checked against child protection plans and there were long-standing severe staff shortages in community nursing services.
Performance management by NHS London was not always effective, and trusts did not always respond to strategic health authorities' requests for information or meetings.
Getting buy-in from clinicians is crucial to entrench child protection systems, says Joanne Robson, South Manchester University Hospitals trust women and children's division general manager.
"We have a very strong governance group that feeds into the board and is chaired by the medical director," Ms Robson says. Six-monthly reports are sent to the board to ensure there is a trust-wide understanding of child protection matters.
Doctors across the trust are given training in child protection, "even if they're not dedicated paediatricians, to spread the message it's everyone's business", Ms Robson says.
Health and social care organisations are likely to see more unified child protection regulation.
Care Quality Commission chief executive Cynthia Bower feels her organisation is in a "strong position to ensure that high quality care is better integrated across services and that different services work more closely and effectively together".
This is because it will absorb the Healthcare Commission, Commission for Social Care Inspection and Mental Health Act Commission. Ms Bower herself has managerial experience across social care and health.
Following the Baby P case, the CQC will be studying follow-up work, such as the Healthcare Commission review, and ensuring that any relevant findings feed into its future inspections programme.
"At all times, our focus will be on the experience of people using services and on outcomes for them," Ms Bower says.
History of violence
Victoria Climbié dies. Pathologist Nathaniel Carey describes the injuries as "the worst case of child abuse I've encountered".
Lord Laming publishes his report into the Victoria Climbié case, which finds 12 missed opportunities to save her.
Every Child Matters green paper proposes children's trusts, amalgamating social services, local safeguarding children boards and an independent children's commissioner.
Government publishes Children Bill to implement green paper's main proposals.
Al Aynsley-Green, England's first children's commissioner, appointed.
Baby P born. In 17 months he is seen more than 60 times by social workers and health professionals.
Baby P dies.
Children's secretary Ed Balls orders an independent inquiry into the roles of the local council, NHS trusts and the police in the case of Baby P.
Joint area review of Haringey's children's services published.
Healthcare Commission asked to investigate trusts involved in the Baby P case and explore whether English trust boards are meeting safeguarding children duties.
Ed Balls orders the removal of Haringey's director of children's services, Sharon Shoesmith. Council leader George Meehan and cabinet member for children and young people Liz Santry resign.
Mr Balls announces a full review of social services.