The Care Quality Commission (CQC) today published a report showing systemic failings in the healthcare provided by NHS trusts to Baby Peter.
The report raises questions about how NHS trusts assure themselves they are meeting important standards for safeguarding children.
Excluding his birth, Peter had 34 contacts with health professionals at North Middlesex University Hospital NHS Trust and Haringey Teaching Primary Care Trust. Both trusts commission paediatric services provided by Great Ormond Street Hospital for Children NHS Trust.
Speaking about the NHS trusts involved in the Baby Peter case, CQC Chief Executive Cynthia Bower said: "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.
"It is imperative to ensure lessons are learnt across the country, as well as in north London. We are concerned that NHS trusts don't always know whether they are doing the right things to safeguard children. Our national review will check what information trust boards use to assure themselves they are getting it right. We will not hesitate to use our powers if we find trusts are not doing enough to ensure appropriate safeguarding procedures are in place."
The report makes clear that since Peter's death the trusts involved have made progress in addressing gaps in child protection procedures.
It highlights improvements including measures to ensure that medical staff have a child's background medical notes when treating or assessing them. Steps have also been taken to ensure that a social worker is present at child protection assessments.
But the report says more work still needs to be done in areas like: ensuring sufficient staffing levels; improving attendance of healthcare staff at child protection case conferences; and addressing communication problems, particularly when making referrals.
This is the first of two reports that CQC will be publishing in relation to child protection in the NHS. Both were requested by Health Secretary Alan Johnson after publication last December of a joint area review of safeguarding in Haringey, which found that agencies were not working effectively together.
This first one brings together for the first time comprehensive evidence on the healthcare provided to Peter including: information from medical notes; the joint area review of safeguarding in Haringey (carried out by the Healthcare Commission, Ofsted and HM Inspector of Constabulary); and Haringey council's serious case review report relating to Peter's care.
In the second report, due out this summer, the CQC will report on findings of a national review of NHS arrangements for the safeguarding of children, which is already underway. The review was triggered by concerns that NHS trusts were not clear on how to ensure safeguarding systems are robust.