Baby P: The Real Untold Story

The BBC documentary 'Baby P: The Untold Story', aired in October 2014, was a study of the public and media response to the Baby P scandal and the impact on professionals. However, consideration should also be given to the impact of Peter's death on the older children in the family. Lessons must be learned from this case to help social workers understand their moral and legal responsibilities when working with parents who may be putting their children's lives at risk. This is a personal reflection on how a narrow focus on 'family support' in social work can lead to dangerous practice.

Shortly after Peter was born his parents separated and his mother, Tracey Connolly, cared for their four children, with the father continuing to see them. Tracey had already established a friendship with Steven Barker. A number of suspicious injuries started being seen by doctors when Peter was about five months old. At the age of seven months, he was taken to the GP by Tracey who said he had fallen down the stairs the previous day. The GP saw he had a bruise on his breast and head. He did not consider informing the health visitor or pursuing it further. This met the threshold of the possible risk of significant harm and social services should have been informed. The response should then have been to make enquiries under section 47 of the Children Act 1989 and to visit the home to investigate how such a young child could have fallen down the stairs and to see whether the family needed help. The fact that GPs do not always alert social services to child protection concerns might be due to difficulties in switching from a helping role to one which might be perceived by the family as the opposite, or their tendency to give priority to medical duties above all else.

When Peter was 8 months old his mother's boyfriend, Steven Barker, moved into the home but Tracey successfully hid this fact. A month later she took Peter to the GP with a swelling to his head which she said she noticed after he had been in the care of her mother. A hospital referral was made and a number of bruises were found on his body and, as the injuries appeared to be non-accidental, a referral was made to social workers. A strategy meeting was held the next day and a decision was made that he could not return to the family home until the section 47 enquiries and police investigation had been completed. Tracey suggested that he could be cared for by a family friend in the meantime and social workers agreed to this.

Tracey was interviewed by the police under caution but denied that she or her mother was responsible. A social work visit to the home was made, presumably as part of the section 47 enquiries, but this was not recorded.

An initial child protection conference was held but it was insufficiently rigorous in obtaining crucial information about the family circumstances and concerns. The GP was not invited, neither was a written report requested. Consequently, medical opinion tended to be discounted and the risk of deliberate harm to Peter played down. The general view was that Peter was active and accident-prone and Tracey had probably failed to protect him from accidental injuries. The arrival in the family of Steven Barker was unknown to social workers and consequently he was not checked out. Too little significance was given to Tracey's own childhood experience of serious abuse and the possible impact of it on her own parenting. Registration of Peter was finally achieved under the categories 'physical abuse and neglect' but the child protection plan was unhelpful in that it lacked a detailed analysis of the dangers a baby in this family was exposed to and how risks might be reduced. Although the risks were serious enough for all four children to be registered only the two youngest ones were.

These were serious injuries to a baby and the mother's denial of abuse needed an authoritative response. With the benefit of hindsight it appears that social workers could have pursued legal proceedings. A legal order would not have precluded the possibility of Peter returning home at a later stage. A comprehensive assessment would then have been carried out to determine whether it would be safe for him to return to his family.

A useful guide to risk assessment can be found in the book 'Working with Denied Child Abuse: The Resolutions Approach' by Turnell and Essex which provides a creative approach for professionals who have every reason to suspect abuse. If this kind of in-depth assessment had been carried out social workers might have discovered that Steven Barker had been suspected of torturing his grandmother and also that he spent a lot of time caring for Peter on his own. This assessment might have also challenged the prevailing view that the relationship between Tracey and her children was largely positive. It is possible that her apparent willingness to co-operate with the child protection plan provided a strong argument for allowing Peter to return home, with the protection provided by registration.

Another alternative would have been for Peter to return home with the protection of a Supervision Order and an agreement that Steven Barker should never be given sole care of Peter. This would have sent a strong message that any physical injury to a child is unacceptable. Tracey would have been in no doubt that Peter would only remain in the family if she could protect him from further serious injuries.

Such a shift in the the social worker's style of working towards control and surveillance would have certainly provoked resentment from Tracey. However, a structured, inter-agency approach was urgently needed to achieve a clearer focus on protection of the children. In addition, the older children in the family would have been seen regularly on their own. Their feelings of loyalty to their mother and suspicion of the social worker might have made them reluctant to talk openly. However, when the social worker demonstrates a serious interest in protecting children this sends a positive message to all of them that they will be heard and taken seriously.

Peter returned home after five weeks without this important work being done. From that point onwards the family received a range of interventions from professionals from local agencies. Tracey turned down the offer of therapy for herself but accepted the involvement of a social worker from the Family Welfare Association. The focus of much work was on improving her parenting of the children. She was referred to a 'Mellow Parenting' course and attended nine of her fourteen sessions with her youngest daughter. Peter was present at some of these sessions, playing in the creche. Various professionals had noted that Peter was an active child who would throw his body around and head-butt family members and objects. This appeared to support Tracey's concerns that her son suffered frequent accidents due to being an active, clumsy child with a high pain threshold.

The home was chaotic, dirty and smelly but Tracey's laziness and lack of housework skills meant this remained an ongoing problem. She needed to be challenged, given practical advice on health and safety issues in the home and told clearly of the consequences if she did not improve her care of the children.

Many risk factors existed and professionals involved should have been made fully aware of the suspicions of physical abuse. Although there were a number of subsequent events which should have rung alarm bells, they did not trigger appropriate interventions.

Firstly, Tracey showed an unwillingness to co-operate with the social worker's request to get rid of the dogs, including a Rottweiler. Then, about four months after registration Tracey took Peter to hospital following an injury to his head which had occurred four days before. She claimed that it was an accident and Peter did not become unwell until that day. He was admitted to hospital for 48 hours observation. Both the hospital and the social work staff were too willing to believe the plausible accounts Tracey was offering to explain Peter's injuries and agreed to him being discharged home.

Two months later the social worker made an unannounced visit and noticed a bruise under Peter's chin. She insisted on a medical examination and this revealed multiple bruises and scratches of different ages and grab mark bruises on the leg that doctors were particularly concerned about. The social worker agreed to him being discharged home. Tracey had been arrested by the police and questioned about the injuries. Although it was reasonable to infer that the injuries were non-accidental the view later developed that the evidence was inconclusive. Managers took the view that they did not meet the threshold for care proceedings. A Child Protection Review Meeting was held but the way it was handled suggested that child protection was not being given high priority. It should have recognised that there were strong grounds for removing Peter immediately and probably the other children too.

Shortly afterwards Steven Barker's brother, Jason Owen, moved into the home with a fifteen year old girl and three of his children. The situation in the home became even more chaotic and the harm to Peter escalated over the following five weeks. On 3 August 2007, two months after the Child Protection Review, Peter was found dead at home. He had more than 50 injuries, including fractured ribs and a broken back. On 11 November 2008, Jason Owen, 36, and Steven Barker, 32, were found guilty of causing or allowing the death of Peter. Tracey Connelly, 27, had already pleaded guilty to this charge.

The social worker had done her best in a difficult situation but managers had let her down due to their uncritical belief in preserving family relationships regardless of the risks. Similar problems existed in many children's services at that time, arising out of uncertainty about the appropriate use of legal powers. Managers seemed to regard laws, not as rules to be followed, but merely as suggestions.

Many aspects of this case will be familiar to child protection social workers who recognise the heavy burden of responsibility they carry. If the profession can now achieve the right balance between care and control and local authorities can be held to account for any weaknesses in carrying out their legal duties there could be a period of improvement in children's services, making it easier to recruit and retain good social workers. This in turn could boost the image of the profession and might even lead to fewer scandals. There are encouraging reports of authorities which have responded constructively to Ofsted criticism now functioning better.

Finally, on the subject of prevention, this case illustrates the huge difficulties for social workers in turning around a dysfunctional family. It should not be forgotten that staff in children's services are actually employed to carry out child protection duties and should be able to recognise any ongoing risks to children in the families they are actively working with. In the Connelly case a more authoritative approach might have prevented Peter from being killed.

Hilary Searing