R (Shoesmith) v Ofsted and Others

JurisdictionEngland & Wales
JudgeMr Justice Foskett
Judgment Date23 April 2010
Neutral Citation[2010] EWHC 852 (Admin)
Docket NumberCase No: CO/2241/2009
Date23 April 2010
CourtQueen's Bench Division (Administrative Court)

[2010] EWHC 852 (Admin)




Royal Courts of Justice

Strand, London, WC2A 2LL


Mr Justice Foskett

Case No: CO/2241/2009

The Queen On the Application of Sharon Shoesmith
(1) Ofsted
1st Defendant
(2) Secretary of State for Children Schools and Families
2nd Defendant
(3) London Borough of Haringey
3rd Defendant

James Maurici (instructed by Beachcroft LLP) for the Claimant

Tim Ward and Ben Lask (instructed by Treasury Solicitors) for the 1 st Defendant

James Eadie QC and Clive Sheldon (instructed by Treasury Solicitors) for the 2nd Defendant

Ingrid Simler QC (instructed by Haringey Legal Services) for the 3 rd Defendant

Hearing dates: 7 th, 8 th and 9 th & 12 th October 2009

Also: 10 th November and 11 th December

Further written submissions and representations between 9 th February 2010 and 18 th March 2010

Mr Justice Foskett

Peter Connelly died on 3 August 2007. He was only 17 months old. In his tragically short life he was the victim of dreadful and sickening physical abuse. Until his identity was permitted to be revealed, he was known in the public consciousness as 'Baby P'. Doubtless for many he still is and it may be the way in which he will be remembered.


In the few weeks or so before he died he had suffered seven fractured ribs, a broken spinal cord, bruising to his face and back and the forceful knocking into his mouth of a tooth which he ingested. The rib fractures and the broken spinal cord would have required the infliction of very considerable force. These were but a few examples of the injuries he had sustained at various times.


Those directly responsible for the injuries that led to his death were his mother, Tracey Connelly, her boyfriend, Steven Barker and Steven Barker's brother, Jason Owen, who was lodging in the house during the relevant period. Barker's presence in the home was concealed from the knowledge of those in authority who visited. Following Peter's death they were arrested and charged with murder. Each was acquitted of murder and the alternative offence of manslaughter during a trial at the Central Criminal Court in the autumn of 2008 — Tracey Connelly and Jason Owen on the direction of the judge, His Honour Judge Kramer QC, at the close of the prosecution case and Steven Barker in due course by the jury. Each was, however, convicted of an offence contrary to section 5 of the Domestic Violence, Crime and Victims Act 2004 of causing or allowing Peter's death, his mother having pleaded guilty at the outset of the trial, albeit on a limited basis which the judge ultimately did not accept.


The sentencing process and the response to it by the Attorney-General and at appellate level, where it has arisen, is in the public domain and has been well publicised.


Judge Kramer said that any decent person who heard about the suffering to which Peter was exposed before his death "could not fail to have been appalled." The Secretary of State for Children, Schools and Families said, following the verdicts in the case, that the case was "tragic and appalling" and that the treatment of Peter was "evil and horrific".


Any number of expressions could have been, and indeed were, used to describe the case and those involved in it. It provoked a universal sense of outrage and gave rise to some strongly expressed views about those who bore either direct or indirect responsibility for Peter's death or who were perceived to have done so. It still does. Attractive or not, justified or not, well-informed or not, strongly expressed views will inevitably follow a case involving the death of a baby in the kind of quite dreadful circumstances that surrounded Peter's life and eventual tragic death. Sadly and depressingly, shocking and heart-rending though the circumstances of his short life were, the story does not reflect a unique occurrence.


According to press reports contained in the papers before the court (and indeed by reference to the transcript of the proceedings that has been provided to me subsequently), in evidence given to the House of Commons Select Committee on Children, Schools and Families on 10 December 2008, Her Majesty's Chief Inspector at Ofsted (the 'Office for Standards in Education, Children's Services and Skills'), Ms Christine Gilbert, said that in the period from April 2007 until August 2008, 210 children, 21 of them babies, died of abuse or neglect in England. In his report prepared in 2009 (see paragraphs 100, 123–124 below), Lord Laming said that "Home Office data shows that in 2007/08 55 children were killed by their parents or by someone known to the child." After the hearing in October 2009 was concluded it was impossible not to note the Ofsted Press Release on 15 October 2009 relating to the publication 'Learning the lessons from serious case reviews: Year 2' which indicated that the 173 Serious Case Reviews (see paragraph 66 below) carried out and completed between 1 April 2008 and 31 March 2009 related to 219 children and included 113 cases of child deaths as a result of an incident – not all, it should be said, because of the kind of neglect and abuse shown in the present case. However, of the 219 children identified, 68% were known to social care services at the time of the incident.


However these various statistics are interpreted, they evidence a sub-culture of abuse and violence to vulnerable children that any civilised person would find totally abhorrent. They offer support for the proposition that the systems presently in place do not always operate to prevent the deaths of children known to the social care services. Reports of other incidents, cases and Serious Case Reviews since then and during the period when this judgment has been pending serve to confirm that proposition.


As will by now be well-known, during a crucial period before and leading up to his death, Peter was the subject of a child protection plan put in place (on 22 December 2006) by the London Borough of Haringey ('Haringey') and was thus on the child protection register. He was one of in the region of 200 children similarly registered in Haringey at the time. He had become registered because of concerns about abuse and neglect. He was seen about 60 times during this period by various social workers, doctors and other health care professionals (whose visits apparently numbered 38) and the police. Tragically, the warning signs of impending catastrophe were not picked up or, if picked up, were not acted upon. In order to put matters in context, it is right to note that Judge Kramer expressed himself satisfied (as indeed have others, including the Secretary of State) that the mother's own wilful deception of the authorities over several months contributed to the failure of those involved with the family fully to appreciate the lurking dangers. Furthermore, the broken spinal cord that was inflicted on Peter some 3–4 days before he died, and which caused or contributed to his death, was not identified by the locum consultant paediatrician, Dr. Sabah Al-Zayyat, who saw him on 1 August. On any view, no-one within Haringey can be blamed for that omission.


After the conviction of those directly responsible, attention was turned to those charged with trying to prevent this kind of terrible tragedy occurring. Why did it all go wrong? How could it happen again in the borough where the Victoria Climbié case had occurred some years previously? That case had also captured the public attention and led to the Laming Report and the statutory scheme that Haringey and all other local authorities with responsibility for children throughout the country had been seeking to put into effect since the implementation of the Children Act 2004 during 2005.


During the period covering Haringey's involvement with Peter the Claimant, Ms Sharon Shoesmith, was the Director of Children and Young People's Services (the 'DCS') within the Borough. She was thus the head of the team responsible for child safeguarding within Haringey, although day-to-day management responsibility for that part of the authority's services was delegated to and undertaken by Cecilia Hitchen, the Claimant's Deputy, whose expertise and experience was in social work. I shall say more about the position of DCS in due course (see paragraphs 61, 75–77 below). The Claimant had become DCS in April 2005 and when Peter died was therefore a little over two years into a newly-created statutory position in a borough where historically the Council and other agencies with responsibility for safeguarding vulnerable children had been shown to be significantly wanting. Along with many of her colleagues who took on such a role elsewhere in the country, her experience was not in social care, but in education. From the outset it is a position that would plainly present anyone, even someone with a social care background, with very significant challenges. When she became DCS there were 5 Deputy Directors within the department, but by 2006 budget constraints had reduced the number to 3.


Prior to the verdicts being returned in the criminal case the Claimant had been a highly valued and respected member of the administration at Haringey. She first went to Haringey as part of the Capita intervention team in 2001 on the direction of the then Secretary of State for Education and Skills following a critical Ofsted inspection report concerning the provision of education services within the Borough. The whole of the senior education team had been replaced. As I have said, her professional experience had been in education. She started...

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