Radiography managers are amongst those criticised for "systemic failings" in the care given to Baby P, before his death.
Health professionals at North Middlesex University Hospital NHS Trust and Haringey Teaching Primary Care Trust had contact with Baby P (who can now be named as Peter) 35 times in his short life. Every opportunity to raise the alarm and save him was missed, the Care Quality Commission found.
The health watchdog stated that any one of the professionals could have picked up that he was suffering abuse if they had been vigilant and gone beyond what was required.
The commission examined the actions of four NHS trusts in London: North Middlesex University Hospital NHS Trust; Haringey Teaching Primary Care Trust; Great Ormond Street Hospital for Children NHS Trust and Whittington Hospital NHS Trust.
All had been involved in Baby Peter's care before his death in August 2007 aged 17 months. Investigators found a "catalogue of errors", including:
* Chronic staff shortages;
* Inadequate training;
* Long delays in seeing the child, and
* Poor communication between health professionals, police and social services.
They highlighted a series of failings when consultant paediatrician Dr Sabah Al-Zayyat saw Baby P at St Ann's Hospital in Tottenham, north London, two days before he died.
Dr Al-Zayyat decided she could not carry out a full check-up because the little boy was "miserable and cranky" and did not spot that he had serious injuries, probably including a broken back and fractured ribs.
The doctor had no contact with Baby Peter's social worker before or after the appointment and was given no details about the child's previous hospital admissions, the commission noted. She was one of only two consultants at the children's clinic at St Ann's Hospital, when there should have been four.
The report also shows that several months before, on 21 December 2006, Baby Peter attended Whittington Hospital paediatric day unit as an outpatient where an x-ray was taken. The images were described as 'not good' and a repeat was planned in the new year. On 17 January 2007 another x-ray was taken, but no abnormality was seen. The film, however, was described as 'poor quality'.
The third and final time Baby Peter underwent imaging was on 9 April 2007 when he his mother took him to A&E at North Middlesex University Hospital. He was admitted for observation due to post head injury and underwent a CT head scan, which was normal. There were bruises and scratches on his face, head and body.
Two days later, Baby Peter was discharged from the hospital without a formal meeting to discuss concerns about possible abuse - contrary to standard procedures.
Baby Peter died less than four months later on 3 August 2007. The post mortem revealed further injuries: a tooth was found in his colon and eight fractured ribs on the left side and a fractured spine were detected. The provisional cause of death was described as a fracture/dislocation of the thoracolumbar spine.
Sue Eardley, the Care Quality Commission's head of children's strategy and safeguarding, said the tragedy occurred because of system failures rather than "individual culpability" by the health workers who saw Baby Peter.
Cynthia Bower, CQC CEO, commented: "This is a story about the failure of basic systems. There were clear reasons to have concern for this child, but the response was simply not fast enough or smart enough. The NHS must accept its share of the responsibility.
"The process was too slow. Professionals were not armed with information that might have set alarm bells ringing. Staffing levels were not adequate and the right training was not universally in place. Social care and healthcare were not working together as they should. Concerns were not properly identified, heard or acted upon.
"The NHS trusts involved have already responded robustly and made clear improvements. But there remain significant further steps that must be taken. We must get to a position where we can say everything possible is being done to prevent a recurrence."
She added: "If somebody had been particularly vigilant and gone beyond their scope, beyond what was required, any one of those could have picked it up."
Audrey Paterson, director of professional policy at the SoR, reiterated this point, commenting: "No member of the radiography team can have been unaffected by the dreadful nature of Baby Peter’s death, the catalogue of abuse during his short life and the shortcomings of the variety of organisations and professionals who could have made the difference. But will Peter’s death have changed how we practice – will each of us be ‘particularly vigilant’ at all times? And will every one of us act if we are concerned or if our suspicions are raised?
"Radiographers are part of the front line when it comes to identifying potential abuse victims; they need to remain aware of this at all times and take action when they are concerned."
Prof Paterson stated that though there is plenty of guidance available, "unnecessary suffering and deaths still occur". She conceded that chronic understaffing and insufficient or inadequate training are factors that lead to inertia and inaction, but said "they do not excuse individuals from their professional obligations.”
To avoid these cases in the future Paterson said radiographers and other healthcare staff must all be "properly knowledgeable, competent and confident that we can act appropriately if we suspect abuse of a child has taken place".
She called for managers to review the relevant policies and procedures of their employer and department, discuss them during staff meetings, and raise the need for additional training if necessary.
"In the Baby Peter case, radiographers were not criticised directly; but they were involved and on at least two occasions produced images that were considered to be poor – itself an adverse reflection," she concluded.
"In the next case, when the chain of events is reviewed, let’s be sure that we will be seen to have exercised vigilance and to have taken proper action.”
Professional guidance
The SoR is to publish a new document for radiographers 'Practice Standards for the Imaging of Children and Young People' later this year.
Three existing documents are already available on the SoR online document library:
• Guidance for Radiographers Providing Forensic Radiography Services 2008
• The Child & the Law: The Roles & Responsibilities of the Radiographer 2005
• Skeletal Survey for Suspected NAI, SIDS and SUDI: Guidance for Radiographers 2009
