MPS response to the death of Baby P

Report: 12
Date: 4 December 2008
By: Assistant Commissioner Specialist Crime on behalf of the Commissioner

Summary

This reports provides a summary of:

• Police involvement with Baby P prior to his death and the subsequent murder investigation and prosecution.
• The Serious Case Review’s recommendations and how the MPS has responded to these.
• Details of other reviews being conducted into Haringey and wider MPS child protection services.
• Changes in demand for child abuse investigation command
• Improvements in information sharing in respect of children coming to notice following enhancements to the Merlin IT system
• The implementation of Every Child Matters and Public Protection Desks within the MPS

A. Recommendation

That

1. Members note the report; and
2. that a further report will be submitted to the SOP Committee on 8 January 2009, following receipt of a report from the joint inspection of child protection in Haringey, currently being conducted by HMIC / Ofsted / Commission for Health

B. Supporting information

Unlawful Killing of Baby P

1. On 3/8/07 17-month-old Baby P was declared dead at hospital with a number of visible injuries. The cause of death was a broken back; other injuries identified posthumously, included eight broken ribs, a fractured leg, an ingested tooth and multiple bruising. Baby P was on the Child Protection Register at the time, the local Safeguarding Board was Haringey.

Murder Investigation and Prosecution

2. The MPS Child Abuse Investigation Command investigated this unlawful killing. The child’s mother, her partner and Jason Owen, were all convicted on 11 November 2008 of allowing or causing the death of the child, but not for murder. The mother pleaded guilty and took the stand but has never provided an explanation of how her son received his fatal injuries; neither of the two men gave evidence in their own defence and pleaded not guilty.

Media

3. These convictions have brought significant media and political attention to the case and further scrutiny is expected when all three offenders are sentenced on 15 December 2008.

4. There are strict media reporting restrictions to protect the identities of all children in the family, the mother and her partner, but these have not been effective in restraining activity on the Internet or by use of texting. On 20 November 2008 a text message was circulated nationally identifying the names and addresses of the three offenders. The identities of the offenders have also appeared on social networking sites such as Facebook and Bebo. The MPS’s Computer Crime Unit is investigating and actions have been taken to prevent further breaches of the court order. Legal advice is being sought and liaison maintained with the CPS and the Attorney General’s office. The names and images of most professionals involved in the case have been published and police have undertaken risk assessments with all those identified and offered target-hardening advice where relevant and requested.

5. Police personnel involved in this case who have been identified in the press have been offered support and welfare advice.

Previous Investigations Relating to Baby P

6. Police received information from Haringey children’s services with regards to non-accidental injuries to Baby P in December 2006 and June 2007. On both occasions the Haringey Child Abuse Investigation Team (CAIT) attempted to pursue a prosecution against the mother and grandmother for injuries believed to be non-accidental.

7. In both investigations, doctors had the opinion that the child’s injuries indicated non-accidental causes, but without independent witnesses and with the mother giving potentially plausible accidental explanations, the Crown Prosecution Service concluded that there was insufficient evidence to support a realistic prospect of successful prosecution. This decision was made and relayed to the mother two days before the child died.

8. It is now clear that the mother concealed relevant facts from agencies and whilst apparently compliant, had been engaged in and was aware of, the abuse the child was suffering. It is also clear that relevant information about the mother’s intimate relationship with a violent man and his associate, and additional injuries suffered by the child in April, July and August 2007, were not reported to police prior to his death. This information may have made a difference and would have raised the known risks and identified additional suspects for causing injuries to the child.

Review of CAIT actions

9. Immediately after the death, SCD5 undertook an internal inspection of a significant sample of other investigations at Haringey CAIT. No cases of concern were identified. Training was delivered to remind staff of the importance of maintaining standards of evidence gathering and supervision. None of the officers involved have been identified as failing to the extent that would warrant any further action other than management advice and training and no disciplinary matters are outstanding.

Serious Case Review

10. A Serious Case Review (SCR) was instigated by the Safeguarding Board to identify lessons to be learned. An MPS internal review was completed by the Specialist Crime Review Group and submitted to the independent authors of the SCR, into actions by the MPS relating to Baby P prior to his death. The MPS internal report identified the following areas for improvement for the CAIT:

11. The main vulnerability concerns a delay of some weeks during March-May 2007 when the investigating officer transferred to another role and the case was not reallocated, contrary to standard operating procedures. During this time, delays occurred in finalising medical evidence, but the medical opinion once secured, did not support further action. This delay was identified in May 2007 and the new investigating officer, in advance of the second referral being made by Children’s Services in June 2007, then instigated active enquiries. Another error was not promptly taking quality photographs of the child’s injuries in December 2006, but relying on medical notes.

12. In both January and June 2007, police officers supported the removal of Baby P from his mother’s care whilst the police investigation continued, but finally agreed to a care plan for the child, as outlined by Children’s Services. It is now known that these plans, which were intended to protect the child, were not subsequently delivered in full and this too is subject to criticism within the SCR. CAIT officers challenged the slow progression of the plan, including the failure for legal advice to be secured within the normal period of seven to ten days. This advice was eventually given on 27 July 2007, six weeks later than expected.

13. Haringey Health Services and Great Ormond Street Hospital also had involvement with Baby P. As a result of information from the murder investigation, serious concerns were identified about the last health practitioner to see Baby P two days before his death when it is now clear he was already suffering significant injuries, including eight broken ribs and severe bruising - again, this information was not reported to the CAIT at the time of the injuries.

14. Following the verdict on 11 November 2008, the MPS spokesperson acknowledged errors in the initial police investigation and sincere regret over the death of the child at the hands of his supposed carers. It is not believed, or suggested by others, that these errors alone had a significant impact on the tragic outcome, but that police acted in good faith on the information available to them at the time.

15. The SCR identified several missed opportunities for appropriate information to be shared between safeguarding agencies and with the police, including information relating to the mother having a new boyfriend and being pregnant. There was also criticism of the failure to progress a referral for specialist paediatric assessment of the child which could have helped refute the mother’s account of accidental causes for his injuries, of delays in securing legal advice and the quality of that legal advice, as to whether care proceedings should be instigated after the June 2007 injuries.

16. The SCR made 43 recommendations for agencies, of which three related to the MPS and have been implemented:

17. 1. Officers within the SCD5 Command should be reminded of the need to ensure that they accurately record all information during criminal investigations, including the need for photographs of scenes, including victims, in line with Standard Operating Procedures. [Digital cameras have been purchased for every CAIT, staff trained and SOPs reinforced at regular training events.]

18. 2. SCD5 Quality Assurance officer should review by ‘dip sample’ Haringey CAIT investigations to assess if these two investigations are reflective of the team’s general standards. [40% of live cases were reviewed and did not identify any other cases of concern - the initial officer-in-the-case’s casework was also reviewed and no other cases of concern were identified. Additional systems to monitor supervision of cases and children with active care plans are also now in place.]

19. 3. Officers of the SCD5 Command should be reminded that they have the capability to request follow up strategy discussions during complex or protracted investigations. [This is reiterated with officers and child protection conference staff at training events and SOPs are being amended to require additional supervision by a DI for all active investigations where there is a care plan.]

Additional reviews

April 2007 Her Majesty’s Inspectorate of Constabulary (HMIC)

20. HMIC carried out a thematic inspection of the MPS in relation to ‘Protecting Vulnerable People’. The inspection covered four key areas: child abuse investigation, vulnerable missing persons, domestic violence and public protection.

21. In relation to child abuse investigation the MPS achieved a rating of ‘Good’, denoting performance above the minimum standard. There are only three forces in England and Wales currently achieving a higher rating.

22. Within the inspection report, a number of strengths were highlighted in relation to child protection matters, including:

• Clear ownership for all aspects of public protection at ACPO level.
• High Tech Crime Unit is developing a reputation as a centre of excellence.
• There is a written accountability framework displayed on the SCD5 website.
• SCD5 fully engages in joint agency reviews.
• ACPO guidance has been fully implemented.
• Performance management system in place within SCD5.
• There is a supervision model used across CAITs.
• There is a structured investigative plan for officers to apply when commencing an investigation, supported by a supervision review process and a closing plan.
• SCD5 is a designated detective command.

23. The inspection contained only one recommendation relating to child abuse investigation: ‘That the MPS works to improve the information exchange process between central units and other elements of the public protection business area’. Following this recommendation seven key milestones were identified to comply with the recommendation, of which four are already complete and the other three are in progress. There were three further areas for improvement identified. These also relate to information sharing, monitoring of MERLIN reports and the capture and dissemination of organisational learning and all are being progressed and monitored.

Joint Area Review of Safeguarding in Haringey

24. On 17.11.08 a two week ‘Joint Area Review’ of safeguarding in Haringey was announced by Secretary of State Ed Balls, to report back to him by 1.12.08. SCD and TP are actively co-operating with HMIC and will, of course, actively respond to the findings. This is being led by Ofsted with input from HMIC.

25. A further internal review of the original crime reports and the internal management report is currently being undertaken to identify any additional missed opportunities or lessons to be learned.

Review of progress against the Laming Recommendations

26. Of the 18 recommendations for police, all have been implemented and are regularly revisited in training events and underpin the national child abuse investigation course which is delivered by SCD5 to all new staff.

27. A detailed update on implementation and additional action taken will be provided to this committee for its January 2009 meeting.

28. Within the recommendations from the SCR on Baby P are two which repeat issues identified by Laming, namely supervision of investigations and the readiness of staff to challenge colleagues in other agencies.

29. These recommendations have been addressed through one to one staff meetings on Haringey CAIT, an SCD5 Supervisors training day on 2 November 2007, Police Conference Liaison Officers annual training, SCD5 weekly monitoring of crime report supervision, in addition to the actions outline at paragraphs 17 to 19.

Increased demand for CAIT services since the Baby P trial

30. SCD5 currently deals with approximately 10,000 allegations of crime per year and over 100,000 Merlin entries last year, anticipated to rise to 280,000 in 2008-9.

31. Since the publicity surrounding Baby P’s death, a significant change has been noted in the number of reports entered on the Merlin system, the number of requests for information and of cases being referred or reviewed by Children’s Services departments and the number of times Police Protection powers are being used across the MPS.

32. In the two weeks prior to the trial verdict, 5,783 Merlin reports were created and 59 children taken into police protection; in the two weeks since, 6,646 Merlins were created and 99 children taken into police protection. The number of children with care plans is also increasing, currently there are 5,419 such children across London and the ability of police and Children’s Services to continue to effectively manage this increase is of concern, should it be sustained. These increases are being closely monitored.

Information sharing

33. The use of Merlin is an effective way of recording concerns about the well-being and safety of children and young people. Merlin is not an investigative system, but is used to record concerns about the well-being and safety of children / young people so that a decision can be made about further police action or to share information with partner agencies.

34. Once information has been recorded, it is sent to the Public Protection Desk (PPD) for the borough where the child lives, or if not known, or the child lives outside of the MPS, the report goes to the PPD where the incident occurred.

35. The PPD will assess the information and undertake further intelligence checks before deciding if or with whom, to share the information. Clear guidance is given to PPD staff on information sharing to meet local expectations, especially on the Common Assessment Framework (CAF) process and a rigorous training programme has been undertaken.

Implementation of Every Child Matters (ECM) across the MPS following the death of Baby P

36. The MPS ECM Programme Board has been chaired at commander level since September 2005. Membership of the board includes representatives from the London Councils, the Greater London Authority, the Association of London Directors of Children Services (ALDCS), Government Office for London (GOL), the Safeguarding Independent Advisory Group (SIAG) and the MPA.

37. To support the delivery of the ECM agenda, two project teams reported progress to the main board. Both teams had clear terms of reference with supporting plans and risk registers. The ECM People Project team was chaired by a Detective Superintendent and delivered the MPS ECM Safeguarding Children Policy and standard operating procedures (SOPs), developed training, the role of PPDs and developed MPS safe recruiting standards for staff working with children and young people. The ECM Systems Project was chaired by a Detective Chief Superintendent and developed a safeguarding children information sharing process and IT solutions.

38. The MPS developed a three-hour classroom based ECM awareness training, delivered as mandatory training to all police officers, up to and including Inspectors, Police Community Support Officers (PCSOs) and front line police staff who come into contact with children and young people, including Dedicated Detention Officers, Forensic Scene Examiners and METCALL staff. Training will be delivered to 38,000 MPS staff; at the end of October 2008 34,022 MPS staff have been trained. There is a new ECM training package for recruits and PCSOs and we have updated current training for investigators.

39. Every Child Matters awareness training emphasises the need for staff to record concerns about the well-being and safety of young people, supported by new Merlin recording thresholds and Safeguarding Children SOPs.

40. To increase the number of staff using Merlin, a computer based training package was developed in May 2008 for police officers and front line police staff. As a result an additional 6,152 users, including 3,199 PCSOs, now use Merlin.

41. In June 2008 the Merlin system was upgraded to include enhancements identified to ensure compliance with the Children’s Act ECM agenda, improve the identification and sharing of information on children and young people at risk of not achieving one or more of the five key outcomes and sharing information in a format compatible with CAF via a new secure e-mail capability between Police, Health and Children’s Services.

42. After these changes, the amount of information recorded on Merlin and subsequently shared with partner agencies, increased from an average of 2,200 reports a week to 6,000 a week in June 2008, an increase of 275% since March 2008.

Public Protection Desks

43. In June 2008 Public Protection Desks (PPDs) were established on each of the 32 BOCUs. Their functions include daily review of information about children and young people recorded on Merlin, the identification of dangerous people and dangerous places, ensuring risks are identified and resources appropriately allocated with oversight by the senior management team on each BOCU and assessing the opportunities to develop information into proactive investigations through established tasking processes.

44. The accreditation process for PPDs includes checks that each is working with sufficient staffing, are able to correctly identify risks or concerns and make the correct decisions about sharing information with partner agencies. To date 21 of the 32 PPDs have been accredited and it is anticipated that all will be accredited by mid-January 2009. Until then, SCD5 continues to lead on initial assessment and risk management of Merlin reports.

45. Co-ordination of information and activity between BOCU PPDs, SCD5 and partner agencies is now closer, with daily exchange of information and requests for action regarding vulnerable people and dangerous people and places. This was a key element of the MPS response to the HMIC inspection of Protecting Vulnerable People in April 2007.

46. A new team has been created to support BOCUs and provide the professional lead for public protection, to support implementation of PPDs, monitor standards of performance and service delivery and ensure recommendations from the HMIC report are adopted. Funding has been allocated to recruit an additional two members of police staff to each PPD as researchers, a total of 64 additional police staff posts across the MPS.

Abbreviations

CAIT

Child Abuse Investigation Team

SCR

Serious Case Review

PPD

Public Protection Desk

CAF

Common Assessment Framework

C. Race and equality impact

There are no known race and equality implications within this report.

D. Financial implications

1. The MPS has been undertaking a programme of investment and training to meet its responsibilities under Every Child Matters. This has included upgrades to the Merlin IT system to make it compliant with the requirements of the Common Assessment Framework across Safeguarding Agencies. It has also involved the creation of Public Protection Desks on each BOCU. Training is also being delivered to 38,000 front line police officers, PCSOs and police staff. This are existing approved programmes and do not require new funding.

2. The publicity surrounding the Baby P case has led to an increase in reports of child abuse. This has been experienced before with other high-profile child death cases. If this increase in workload proves to be enduring, there will be a need to review staffing and resource levels within SCD5, the Child Abuse Investigation Command.

3. Lord Laming has been commissioned to undertake a national review of safeguarding. This review is likely to lead to new recommendations and these in turn are likely to have resource implications. At this stage it is not possible to give an indication of the scale of the impact. However, the resource implications from his first national review after the death of Victoria Climbié were substantial.

E. Background papers

None

F. Contact details

Report author: Detective Superintendent Caroline Bates, MPS

For information contact:

MPA general: 020 7202 0202
Media enquiries: 020 7202 0217/18

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