Health Secretary Alan Johnson has ordered NHS chief executives to carry out a national review of their child protection services in the wake of strong criticism of a number of NHS organisations involved in the care of Baby P.
Mr Johnson says the joint review by Ofsted, the Healthcare Commission and the Chief Inspector of Constabulary into the "tragic and disturbing" case of Baby P who died from abuse despite being seen by professionals 60 times highlights clear failures by the local NHS organisations to communicate properly and share information and expertise.
Mr Johnson said: "These failures are unacceptable. The protection of vulnerable children requires the very highest levels of performance. We urgently need to learn the lessons of this appalling case.
"I have today asked the Healthcare Commission to undertake a swift analysis of whether health organisation boards are applying national child protection standards as vigorously as they should be.
"The Healthcare Commission has also agreed to review the role of local NHS organisations in Haringey in the circumstances of the death of Baby P, looking in particular at communication between healthcare professionals and organisations and awareness of child protection procedures working closely with the new Serious Case Review. The Commission will also be working closely with Ofsted in its ongoing work.
In addition, David Nicholson, the chief executive of the NHS, is today writing to all NHS organisations. He expects them to review their arrangements for child protection, play their full part in child protection arrangements and ensure that professional staff are receiving appropriate child protection training within their continuing professional development."
The GMC is conducting a seperate investigation into the conduct of Dr Sabah al-Zayyat, a locum paediatrician, who examined Baby P at St Ann's Hospital in London on 1st August 2007, two days before he died. She has been suspended from practicing medicine pending a full hearing.
The inspectors found insufficient strategic leadership and management oversight of safeguarding of children and young people from Haringey by elected members, senior officers and others within the strategic partnership.
They said the management reviews submitted by Whittington Hospital NHS Trust, the Metropolitan Police and Haringey Legal Services are judged good. The review submitted by the Family Welfare Association is judged adequate.
"However, inadequate individual management reviews were provided by the Haringey children’s social care service, Haringey schools, the North Middlesex University Hospital, Great Ormond Hospital NHS Trust, Haringey Teaching Primary Care Trust, Haringey Strategic and Community Housing Prevention and Options Team," the report stated.
The individual management reviews provided by social care services and the primary care trust lack rigour in their analysis and thus significantly undermine the integrity of the serious case review."
Overall they said there had been a "managerial failure" to ensure full compliance with some requirements of the inquiry into the death of Victoria Climbie, such as the lack of written feedback to those making referrals to social care services.
The local safeguarding children board (LSCB) fails to provide a sufficient challenge to its member agencies. This is further compounded by the lack of an independent chairperson.
"Social care, health and police authorities do not communicate and collaborate routinely and consistently to ensure effective assessment, planning and review of cases of vulnerable children and young people.
"Too often assessments of children and young people, in all agencies, fail to identify those who are at immediate risk of harm and to address their needs.
"The quality of front line practice across all agencies is inconsistent and not effectively monitored by line managers. "
It recommends that the Haringey Council, working with its partners and in particular health and the police, should improve governance of safeguarding arrangements.
In particular, they should ensure full compliance with the guidance contained within "Working Together to Safeguard Children" 2006 and embed the London protocol for inter-agency working to improve outcomes for children and young people.
It makes a range of recommendations and calls on all three agencies to establish more secure assessment and earlier intervention strategies which ensure that, in all cases where concerns about children are identified, agencies can intervene and assess risks of significant harm to children in a timely manner.