One of the most shocking aspects of the tragic death of Baby P, tortured to death in Haringey, is that it was preventable. Baby P was already on Haringey council's at-risk register, and was seen by professionals 60 times. The joint area review into the council, which was submitted yesterday to Ed Balls, the Children's Minister, has delivered a devastating verdict. Mr Balls listed a large number of shortcomings, including a failure to talk to children believed to be at risk. It is quite right that the leader of the council, the cabinet member for children and young people, and Sharon Shoesmith, the director of children's services, have all stepped down. They should not have waited so long.

Haringey's management of child protection was clearly a shambles. Yet it was “compliant” with many of the systems put in place since the horrific death of Victoria Climbié. Last autumn Ofsted, newly appointed as the children's inspectorate, delivered a glowing verdict on Haringey's child protection services, awarding that department its highest rating of three stars. Ofsted said that “thorough quality-assurance systems are in place”. But ticking a box for targets such as the speedy completion of comprehensive assessments is not the same as protecting an innocent child from being tortured to death.

This raises the question of whether better implementation of existing systems is the whole of the answer. Lord Laming's insightful 2003 review into the Climbié tragedy recommended, among other things, greater co-ordination between health, education and social services. Mr Balls has called for every local authority to set up a children's trust. But Haringey already has one. In October the Audit Commission found that arrangements to co-ordinate children's services were “confused and confusing”.

Child protection work is taxing. But there is no excuse for bad management in this any more than in any other public service. There are 121 social worker posts in Haringey, and 191 children in Haringey with child protection plans. That is surely not an impossible ratio to manage. Yet no one seems to have been responsible for Baby P.

What should be done? First, urgent action is clearly needed within Haringey. The replacement of Ms Shoesmith with John Coughlan, a highly respected professional from Hampshire, bodes well, although ministers must be prepared to consider hiving off child protection from Haringey altogether if necessary, as was done with Hackney's schools.

Secondly, child protection must be open. It is quite wrong that Mr Balls has refused to publish Haringey's serious case review, citing a 2006 decision by the Information Commissioner. The commissioner has written to The Times to state that this decision would not necessarily apply to Baby P. The stakes are too high to let secrecy shield incompetence.

Thirdly, the national review should be con- ducted in a similarly open and honest way. Lord Laming has been put in charge of a review that seems to encourage him to find that his post-Climbié reforms were correct, and which chiefly asks him to examine whether they are being properly implemented. There is a case for a much wider review, conducted by a more independent figure, while simultaneously improving management in Haringey.

Governments tend to reach for joined-up solutions. But co-ordination can actually disperse responsibility. Baby P died because no one took responsibility for him. Each child on the at-risk register needs a social worker who sees themselves as responsible for that child: not rushing to take them into care, but making an active judgment. Baby P's death was an unbearable failure of responsibility, at every level.