"This was a young life cut tragically short and our thoughts are with his father and family," said Sharon Shoesmith, chair of the Haringey Local Safeguarding Children Board.

Social workers, health visitors, doctors and nurses saw mother and child 60 times over the last eight months of his life. But both mother and her boyfriend have admitted deliberately deceiving the very people trying to help.

Sharon Shoesmith said:

“We worked hard to support the family– social workers, health visitors, doctors and nurses all saw him and his mother regularly.

“We made arrangements to protect him, monitoring his progress and organised for the mother to go on a parenting course.  We arranged for a family friend to help with his care, a childminder to look after him four days a week and report any suspicious injuries.  

“The mother seemed to be co-operating with us: taking the child to doctors when he was ill, seeking help.

“In line with Government guidelines for such circumstances, we immediately set up an independent review into what happened and have acted on every recommendation.  The executive summary has been published today.”

Dr Jane Collins, chief executive of Great Ormond Street Hospital which provided paediatric services to the child, said:

“As part of this review, I commissioned independent experts to look at the decisions and actions of medical staff in this case.

“It is clear that more should have been done when the child was seen by a paediatrician two days before the child died.

“The review process is important in understanding what happened and how procedures can be strengthened for the future.

Where we have needed to act, we have done so.”

The report says that there were “numerous examples” of good practice within all agencies involved in the case, but concludes:

“There were many factors which contributed to the inability of the agencies to understand what was happening to Child A.  With the possible exception of the paediatric assessment of 01.08.07, none on their own were likely to have enabled further responses that might have prevented the tragic outcome.”

The report says that just over a week before he died, legal advice was that on the information provided, the threshold for initiating care proceedings had not been met and adds: “Most critically Child A was seen on 01.08.07 by a community paediatrician for the purpose of the long awaited development assessment.  Expert medical opinion commissioned during the course of this serious case review concluded that a diagnosis of abuse should have been made at that point.”

It also says: “This serious case review has revealed clear evidence of appropriate communication between and within agencies as well as weaknesses in specific areas of information flow.”

The review found that “safeguarding structures exist across Haringey agencies and offer a sound framework for the implementation of required procedures, it has also identified scope for improving the detailed application of some processes.”

Councillor Liz Santry, Cabinet Member for Children and Young People said:

“It is a matter of the deepest sorrow that Baby P died in Haringey.

Our priority has to be and has always been to safeguard children in our borough and as an authority we were all devastated by the death of this child.

That is why, in light of the tragic death, the verdict and the publication of the serious case review executive summary we welcome the additional help and support the Government’s proposed review of Haringey Council’s children and young people’s services will offer.

We have also arranged for additional management support from within local government during the review.

In addition to the proposed Government assistance, we will commission an independent expert, most likely leading counsel. Our aim is to have a cross-party member body to review the actions taken by our staff and the member oversight of child protection in the borough. This should commence immediately.

We recognise that the people of Haringey must have full confidence in the support we provide to those who cannot support themselves.

The council moved swiftly after the death of Baby P to check our child protection procedures, and strengthen them where necessary. An independently written Serious Case Review (SCR) was set up immediately - strictly in accordance with Government guidelines - to investigate the death and all partners’ involvement. Further measures included a check on all children with a child protection plan, an independent audit of child protection processes, additional staff training and an independent review to ensure all the Laming Report’s recommendations had been implemented.

If any further recommendations arise over the coming weeks we will not hesitate to act on them. We want our child protection to be the very best possible.”