A damning report is to identify a catalogue of errors made by NHS professionals who failed to prevent the abuse and death of Baby P.
An investigation by the Healthcare Commission will condemn blunders made by a succession of doctors and health visitors who came into contact with the toddler, but did not act on clear signs that he was at risk. The report, due to be published on Tuesday, will blame poor "joint working" between frontline staff who treated Baby P for the failure of two hospitals, a family doctor and two health visitors to protect the child from violence and eventual murder at the age of 17 months by his mother's boyfriend.
A GP who first raised the alarm about the toddler's abuse was suspended two weeks ago, as it emerged that he had seen the child at least 14 times before his death. Dr Jerome Ikwueke referred the child to hospital in December 2006, calling for a full child protection "alert" when his mother could not explain why the child had bruises and a two-inch swelling on his forehead. However, the GP saw the child on many more occasions, including once two months earlier when he accepted claims that bruises on Baby P's head and chest had been caused by a fall. The General Medical Council suspended him after a complaint from Haringey Teaching Primary Care Trust (TCPT), which oversees the area's GP and health visitor services.
A paediatrician who failed to examine the boy because he seemed "cranky," missing the fact that his back and ribs were broken, has already been suspended. Dr Sabah al-Zayyat saw bruises on Baby P when he was referred to her child development clinic, but did not carry out a full examination, 48 hours before the child died in August 2007, after suffering appalling abuse at the hands of his mother, her boyfriend and their lodger, Jason Owen.
The probe by the Healthcare Commission examines the parts played by four organisations which came into contact with Baby P: Great Ormond Street Hospital for Children NHS Trust, Haringey TCPT, North Middlesex Hospital and the Whittington Hospital, all in north London. It is expected to be most critical of the failings of the Great Ormond Street trust, which employed Dr al-Zayyat, and of Haringey TPCT, which employed two health visitors who visited Baby P.
The inspectorate has already been involved in a review of the borough's child protection system which was published in December. Its chief executive, Anna Walker, described the case as "one of the saddest and most shocking ... on which we have ever been asked to report" and identified systems which were not adequate to enable healthcare organisations to protect children.
The new report, which follows more detailed interviews with staff at all four NHS organisations which treated Baby P, is expected to highlight poor communications between staff and different agencies which came into contact with Baby P. The report will also examine staffing levels, training, and awareness of child protection procedures.
In December, Ofsted ruled that a serious case review into the circumstances leading to the death of Baby P, which was carried out by a "safeguarding children board" headed by Sharon Shoesmith, then director of children's services for Haringey Council, was inadequate. Ms Shoesmith was subsequently sacked and Ed Balls, the Children's Secretary, demanded that a fresh review, examining the blunders made by all the agencies which came into contact with the child, report to Ofsted by the end of February. Ofsted admitted that the deadline had been missed, and Mr Balls has given officials until Friday to submit their findings.
The original report had claimed there had been "appropriate communication between and within agencies", even though Baby P was seen 78 times by social services, health workers and police during months of abuse.
As the Healthcare Commission publishes its investigation on Tuesday, the Local Government Association will launch a campaign to recruit and retain social workers following criticism of the profession in the wake of the Baby P case. Council leaders fear there will be fewer people applying to work with children and more social workers leaving their jobs as a result of the affair.
Baby P's mother, 27, her boyfriend, 32, and lodger Jason Owen, 36, have all been warned to expect significant jail sentences over the death of the child, but sentencing has been delayed for legal reasons.
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