NHS attacked for Baby P 'failings'

Doctors and other health workers had contact with the little boy 35 times in his short life but every opportunity to raise the alarm and save him was missed, the Care Quality Commission found.

Any one of these professionals could have picked up that he was suffering abuse if they had been "particularly vigilant" and gone "beyond what was required", the health watchdog said.

The commission examined the actions of four NHS trusts in London involved in the care of Baby P, who can now be named as Peter, before his death in August 2007 aged just 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 workers, 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 P's social worker before or after the appointment and was given no details about the child's previous hospital admissions, the commission noted in a report. She was one of only two consultants at the specialist children's clinic at St Ann's Hospital, when there should have been four.

On an earlier occasion, in April 2007, Baby P was discharged from North Middlesex University Hospital in Edmonton, north London, without a formal meeting to discuss concerns about possible abuse - contrary to standard procedures.

Sue Eardley, the Care Quality Commission's head of children's strategy and safeguarding, said it was a problem of system failures rather than "individual culpability" by the health workers who saw Baby P. But 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."

Tracey Baldwin, chief executive of NHS Haringey, said her trust was making "fundamental changes right across the board". She said: "We are deeply sorry for this tragedy and apologise without reserve for the failures identified in this and other reports. We failed to understand the level of danger that Baby Peter was in and what he needed to be safe. We, along with the whole country, have been moved by the sad life and tragic death of Baby Peter. Our apology is heartfelt, and matched by our absolute commitment to create an NHS service for vulnerable children that is exemplary."