Last updated: 03.12.19

Serious Case Review: Baby P (2009)

Local authority: Haringey

What happened?

Peter Connelly (Baby P) died on August 2007 at 17 months of age, following months of abuse carried out by his mother, her new boyfriend and a lodger at the family home. Peter suffered more than 50 injuries and had been visited 60 times by the authorities in the eight months prior to this death. Ten agencies were involved with Peter or his family. Peter was placed on the ‘child protection/at risk’ register on 22 December 2006, though insufficient actions by professionals and agencies failed to protect him.

‘Baby P’ suffered horrendous physical abuse, including a broken back, fractured shinbone, damage to the head, blackened fingers and toes from cigarette burns, missing finger nails, cuts to his neck and loss of soft tissue and rib fractures.

To read the full serious case review regarding Baby P, click here.


• Lack of professional curiosity: The agencies involved with the family and Peter displayed a lack of professional curiosity. They were too willing to believe the accounts Peter’s mum gave of herself, her care of her children, her household and nature of her friendship network.

• Lack of openness and transparency: The medical professionals did not attend Peter’s child protection conference to provide insight in the severity of the injuries he had sustained. This meant Peter was allowed to return home to the abusive environment he lived in.

• Failure to protect siblings: Peter lived with other siblings, though authorities failed to place them on a child protection register to reduce the risk of abuse to them.

• Poor response by local authorities: Poor response by local authorities to protect Peter, failure to provide a proportionate response to the seriousness of injuries Peter experienced.   Quicker interventions and responses were required to protect Peter.

• Lack of necessary awareness: Social services did not know who was looking after Peter at all times, and in light of his child protection plan, there should have  been an awareness of who was caring for Peter at any one time.

Impacts on practice

• Working Together to Safeguarding Children: Publication of statutory guidance, ‘Working Together to Safeguard Children’ (2010), which aimed to support multi-agency working and joined up approaches to child protection.

• Social Work Taskforce: Set up of the government’s Social Work Taskforce to make improvements to the recruitment, training and supervision of social workers. This contributed to the development of the current Professional Capabilities Framework (PCF).