The Care Quality Commission (CQC) also found that there was a lack of awareness about child protection procedures among NHS staff in Haringey, north London at the time of the toddler’s death in 2007.
Health visitors and school nurses in the area reported ongoing problems with communication that led to difficulties making referrals.
A shortage of nurses and other staff at St Ann’s Hospital, Haringey also contributed to delays seeing children, according to the CQC.
The CQC recommends that all staff are given safeguarding training appropriate to their role, and advised NHS trusts to employ at least one doctor and one nurse to lead on safeguarding children.
The CQC is conducting a national review to provide a set of indicators, which will be used to monitor trusts’ child protection standards in the future.
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