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Baby Peter Serious Case Review: statement from chairman Graham Badman

Baby Peter Serious Case Review – Executive Summary
Statement from Graham Badman (22 May 2009)


I am today publishing the executive summary of the second Baby Peter Serious Case Review.  This second review was conducted at the direction of the Secretary of State for Children, Schools and Families.  Ofsted had evaluated the first review as being “inadequate”.

This second review was conducted by a new panel that I convened following my appointment as the independent chair of Haringey Local Safeguarding Children Board in December of last year.

This review was completed some time ago as was the executive summary.  I was keen to publish the executive summary as soon as possible but received legal advice that precluded publication at that time.  Having made a number of minor adjustments to the executive summary I am advised it can now be published and I am able to publish it today.  It has, of course, been drafted with due regard to the protection of others.

I am keen to stress that none of the necessary changes that have been made for legal reasons have in any way altered the thrust or direction of the document and the findings, recommendations and key points are all exactly as they were in the original draft.


This second Serious Case Review reaches a number of important conclusions.  It says the actions of the protecting professions were lacking in urgency, lacking in thoroughness and insufficiently challenging to the child’s mother.

It says staff adopted a threshold of concern for taking children into care that was too high and had expectations of what they themselves could achieve that were too low.

It is clear from the Serious Case Review that every member of staff in every agency involved with Baby Peter was appropriately qualified, well motivated and wanted to do their best to safeguard him.  But his horrifying death could and should have been prevented.

The Serious Case Review says that if doctors, lawyers, police officers and social workers had adopted a more urgent, thorough and challenging approach the case would have been stopped in its tracks at the first serious incident.  Baby Peter deserved better from the services that were supposed to protect him.  It’s a dreadful tragedy that he did not receive better protection.

Cases like that of Peter involve problems or raise questions that are not unique to Haringey.  The most important lessons from this case need to be learned across Britain and placed in the context of the government’s determination to safeguard children.  The Laming report and the government’s response to it set a new context for child protection in Britain.

I believe the most important lesson arising from this case is that professionals charged with ensuring child safety must be deeply sceptical of any explanations, justifications or excuses they may hear in connection with the apparent maltreatment of children.  If they have any doubt about the cause of physical injuries or what appears to be maltreatment they should act swiftly and decisively.

The future

I wish to place on record that during the period in which we conducted this second review I received excellent cooperation from the agencies involved and I found them willing to face up to their previous mistakes and willing to make changes rapidly.  In many respects change has already taken place or is clearly in hand.

I am confident the current managers and staff of the agencies involved in this particular case are responding to the challenges of learning the key lessons and implementing change.

This Serious Case Review is not an end in itself, but a step on the way to ensuring that professionals responsible for the care of vulnerable children achieve the highest quality of practice, both individually and collectively.  If this review provides any form of legacy for Baby Peter it is that the lessons ensure the greater safety of children and young people elsewhere.

Attached files

File nameFile TypeFile Size
Child A Executive Summary - ContextPDF48KB
Child A Serious Case Review Action Plan 2009PDF869KB

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