Areas of Learning: Victoria Marten

Areas of Learning – Protecting all vulnerable babies better:
National safeguarding practice review into the death of baby Victoria Marten

The review highlights that safeguarding systems struggle most when parents persistently do not engage with services, avoid assessment or withhold information, significantly limiting professional understanding of risk.
Non‑engagement should not be viewed simply as refusal; it is often rooted in trauma, fear, grief and mistrust following previous child removals.
Trauma‑informed practice is essential, but must operate alongside clear accountability for child safety, as trauma does not remove parental responsibility.
The review identifies a lack of sustained, coordinated support for parents before and after care proceedings, which contributes to escalating risk and repeated concealment in subsequent pregnancies.
Non‑engagement must not block safeguarding systems; instead, it should trigger active multi‑agency reflection, persistence and problem‑solving.

Unborn babies and infants are at greatest risk when they remain unseen by services, particularly where pregnancies are concealed or disclosed late.
The review highlights that concealed pregnancy frequently follows previous child removals and should be understood as a significant safeguarding indicator, even though there is no legal duty to disclose pregnancy.
Safeguarding systems are often reactive, with limited capacity to anticipate future pregnancies once proceedings conclude.
The review calls for stronger, earlier and more consistent pre‑birth safeguarding, grounded in anticipatory and multi‑agency practice that seeks to prevent harm rather than respond after birth.

The review identifies significant risk where a parent or carer has a history of serious violent or sexual offending and child safeguarding and offender management systems operate in parallel rather than as an integrated response.
Management at MAPPA Level 1 can limit structured multi‑agency oversight, particularly where non‑engagement or changing family circumstances are present.
Persistent non‑engagement by serious offenders should itself be treated as a safeguarding risk indicator.
The review emphasises that child safeguarding must be regarded as core business within offender management arrangements, with criminal justice expertise informing child protection decision‑making.

Domestic abuse, including coercive control, is identified as a central safeguarding risk for babies and very young children.
The review highlights that abuse may remain hidden where victims deny harm, present confidently or disengage from services, reducing professional insight into risk.
Failure to use specialist domestic abuse pathways and multi‑agency risk forums limits understanding of the dynamics of harm for children.
Domestic abuse must be embedded as core business in child protection, requiring integrated adult and child safeguarding responses and proactive multi‑agency management.

Frequent and unplanned movement between local authority areas significantly increases safeguarding risk, particularly for unborn babies and infants.
The review identifies that safeguarding systems often lack clear mechanisms to maintain oversight and accountability when families move repeatedly or live transiently.
Poorly managed transfers, delays and incomplete information sharing can result in critical safeguarding knowledge being lost.
Movement should be treated as a potential risk indicator rather than a neutral administrative issue, triggering proactive multi‑agency safeguarding responses.

Across all areas, the review highlights that safeguarding systems remain too reactive, relying on crisis‑driven intervention rather than anticipatory, preventative practice.
Effective protection of vulnerable babies requires whole‑system responsibility, integrating adult services, health, criminal justice and voluntary sector partners with children’s social care.
Leadership, culture, professional curiosity and multi‑agency coordination are as important as procedures in preventing babies from becoming invisible to services.