Health workers missed dozens of opportunities to identify abuse being suffered by Baby P before his death because of “systemic failings” in the care given to the child, an official report has found.

The inquiry into NHS failings, conducted by the Care Quality Commission and published today, concludes that doctors and other health professionals had contact with the little boy 35 times but every chance to raise the alarm was missed.

Any one of these professionals could have picked up that he was suffering abuse if they had been “particularly vigilant” and gone “beyond what was required” by the system, the health regulator said.

The commission examined the actions of four NHS trusts in London involved in the care of Baby P, who can now be named as Peter, before his death in August 2007 aged 17 months.

Investigators found a “catalogue of errors”, including chronic staff shortages, inadequate training, long delays in seeing the child and poor communication between health workers, police and social services.

The commission also raised concerns at how the four trusts — North Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust, Great Ormond Street Hospital for Children NHS Trust and Whittington Hospital NHS Trust — rated key services linked to child protection as compliant with core NHS standards.

Three of the four trusts declared themselves compliant in all relevant standards in each of the three annual health checks collated by the Healthcare Commission, the predecessor of the Care Quality Commission, before Peter’s death.

Peter was on the at-risk register when he was found dead in his blood-spattered cot in Haringey, North London, on August 3, 2007. He had suffered 50 injuries despite receiving 60 visits from social workers, doctors and police over the final eight months of his life.

Last year his mother, her boyfriend and their lodger were convicted at the Old Bailey of causing or allowing his death. This month the boyfriend was also found guilty of raping a two-year-old girl.

The commission said that its findings had been sent to the trusts in March and action plans had been produced to address care shortfalls that had still not been addressed. Publication of the report was delayed until today to avoid prejudicing the related court case.

The report highlights a series of failings when Sabah al-Zayyat, a consultant paediatrician, saw Peter at St Ann’s Hospital in Tottenham, North London, two days before he died.

Dr al-Zayyat decided that she could not carry out a full check-up because the little boy was “miserable and cranky”, and she did not spot that he had serious injuries, probably including a broken back and fractured ribs.

The doctor had no contact with Baby P’s social worker before or after the appointment and was given no details about the child’s previous hospital admissions, the commission noted in a report. She was one of only two consultants at the specialist children’s clinic at St Ann’s Hospital, when there should have been four.

On an earlier occasion, in April 2007, Baby P was discharged from North Middlesex University Hospital in Edmonton, North London, without a formal meeting to discuss concerns about possible abuse — contrary to standard procedures.

Sue Eardley, head of children’s strategy and safeguarding at the Care Quality Commission, said that it was a problem of system failures rather than “individual culpability” by the health workers who saw Baby P.

She added: “If somebody had been particularly vigilant and gone beyond their scope, beyond what was required, any one of those could have picked it up.”

Cynthia Bower, the commission’s chief executive, said it was vital that lessons from the case were learnt across the country as well as in North London. She added that stronger legal powers would ensure that, from next year, trusts could be held to account for inaccurate claims of competence.

“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. 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.”

The commission is carrying out a review of all NHS trusts in England to check that they are doing enough to protect vulnerable children. It will be published in July.

The General Medical Council has suspended from practice Dr al-Zayyat and Baby P’s family GP, Jerome Ikwueke, over their involvement in the case.

The NHS trusts criticised in the report apologised for failings in the Baby P case and said that they had taken steps to address them.

Alan Johnson, the Health Secretary, said that the report highlighted “clear failures by local NHS organisations to communicate properly and share information and expertise”.

“These failures are unacceptable. The protection of vulnerable children requires the very highest levels of performance. We must do all we can to learn the lessons of this appalling case.”

Mr Johnson, who ordered the commission’s review in December, pledged that the recommendations would be “rigorously applied” across the health service.

Seen but not spotted

During the period March 1, 2006, to August 3, 2007, a number of health professionals had numerous contacts with Baby P, including:

6 visits by Baby P to an acute hospital (excluding his birth and death). Of these, two were to the North Middlesex University Hospital A&E department, one was to the Whittington Hospital paediatric emergency clinic and three were outpatient appointments (one for paediatric assessment and two for X-rays)

14 visits to the GP practice

1 visit to the specialist child health service, where a consultant paediatrician saw Baby P two days before his death

5 visits by a health visitor in which Baby P was seen at home

6 visits to the child health clinic

2 visits to walk-in centres

1 contact specifically with the midwife

9 attendances by Baby P’s mother at Mellow Parenting sessions, of which five were with Baby P

16 contacts between Baby P’s mother and the primary mental health worker

Source: Care Quality Commission