‘Protecting All Vulnerable Babies Better’ – learning from the National Panel Review into the Death of Baby Victoria Marten

Purpose of this briefing

This briefing summarises national learning relevant to all Devon multi‑agency practitioners working with unborn babies, infants and their parents. It aims to strengthen trauma‑informed, restorative and relational safeguarding practice, ensuring that vulnerable babies are protected through persistent, coordinated and compassionate professional efforts.

Core themes from the national review

Parental non‑engagement

Non‑engagement limits practitioners’ ability to understand family life, assess risk and build relationships. It may be a trauma response, not deliberate avoidance. Trauma, shame and grief, especially following child removal, can drive withdrawal. Non‑engagement is a safeguarding risk factor requiring coordinated multi‑agency response.

Concealed or late booked pregnancy

Concealment can stem from fear of further child removal, domestic abuse or coercion, trauma, mistrust or exploitation and a lack of safety to disclose.  There is no legal duty to disclose pregnancy, making proactive relational approaches essential.

Domestic abuse & coercive control

Domestic abuse is one of the most significant risks to babies under 12 months. Compliance with coercive control is a survival strategy by the victim to manage risk. Coercive control can prevent engagement with routine services, lead to denial or minimisation of any abuse, and limit ability to engage with services.

Routine enquiry about domestic abuse is essential, including where abuse is not immediately disclosed or suspected. The national learning highlights that coercive control often remains hidden and that denial or minimisation can be a survival strategy. Practitioners should therefore ask about domestic abuse sensitively and repeatedly over time, recognising that disclosure may only occur once trust and safety are established.

Serious offender risk (MAPPA)

Safeguarding risks increase when offender management and children’s services work in isolation. Non‑engagement by serious offenders must be treated as a risk indicator. Child safeguarding must be central to MAPPA processes.

Families who move frequently

Repeated relocations disrupt professional oversight and may indicate flight from services, coercion or control and attempts to avoid statutory intervention. High‑quality, ready‑to‑share summaries and robust transfer processes are essential.

What does good multi‑agency practice look like?

We are trauma-informed & caring

We ask,“what has happened to this parent?” not “what is wrong with them?” and we reduce re-traumatisation by offering choice, clarity and emotional safety.

We are persistent and relational in our engagement

Our practice is relational and persistent, even when safeguarding timescales are tight, using every contact to build trust, offer clarity and help families feel supported in keeping their child safe.

We always ‘Think Family’

We recognise that parents’ needs can be safeguarding needs. We understand that our relationships with adult services partners are essential (adult social care, mental health, substance use, domestic abuse, housing) to helping a parent meet a child’s needs.

We engage in effective multi‑agency reflection

We create spaces to think together about stuck cases, non‑engagement and patterns across time, and we know that shared interpretation is as vital as information sharing.

We are proactive about our planning for future pregnancies

After child removal, support must continue long‑term. We must address grief, trauma and practical needs and anticipate potential future pregnancies.

What we can do? Practical steps for Devon practitioners

When parents do not engage

• We can treat avoidance as a signal of need, not label as non‑compliance.
• We can explore underlying trauma, fear or shame.
• We can use supportive, non‑judgmental communication.
• We can record and document patterns clearly.

When pregnancy is concealed or suspected

• We can make sure we consider contextual history (previous removals, domestic abuse, mental ill-health, avoidance).
• We can see early, relational and multidisciplinary planning as critical.
• We can ensure antenatal concerns are recorded clearly in records.

When families move

• We can prepare up to date chronologies and concise, portable summaries.
• We can treat multiple moves as potential indicators of risk
• We can use CP‑IS and the Missing Person Protocol appropriately.

When serious offenders are involved

• We can request MAPPA advice early (Devon MAPPA Coordinator DevonandCornwallMAPPA@justice.gov.uk)
• We can make sure that information flows between police, probation and children’s services.
• We can consider ‘not knowing’ as an elevated risk.

When domestic abuse is denied or minimised

• We can assume coercive control may be present even without disclosure.
• We can seek specialist advice and consider MARAC referrals.
• We can watch for patterns of isolation, fear and shifting stories.
• We can conduct routine enquiry safely by considering when, where and how questions are asked.

Some reflective questions for teams to use

You could use these in supervision, team discussions, multi‑agency forums or case reviews:

1. What might be driving this parent’s behaviour (fear, grief, trauma, coercion)?
2. Could past or current sexual violence, including around conception, be impacting this parent’s trauma, mental health or capacity to bond with their baby, and have we created safe opportunities to explore this?
3. Are we working with adult services as actively as with children’s services?
4. Have we created space to think together, or are agencies working in isolation?
5. What support do the parents need beyond statutory proceedings?
6. Are we curious about the possibility of a concealed pregnancy?
7. How well have we documented domestic abuse and coercive control?
8. If the family moved today, would essential information be lost?
9. Are we showing compassionate curiosity while keeping clear boundaries?
10.  Are our processes accidentally retraumatising for parents?
11.  What would a restorative, trust‑building step look like here?

Key messages to take forward

• Every unborn baby must be held in mind early, proactively and compassionately.
• Engagement is safeguarding.
• Trauma‑informed practice reduces risk.
• Multi‑agency collaboration saves lives.
• Parents’ trauma and grief must be supported, not overlooked.