England review: act earlier to protect unborn babies

A national review in England is calling for earlier, joined-up action to keep unborn babies and infants safe. It follows the case of baby Victoria, born in December 2022 and who died in early 2023 after her parents concealed her birth and avoided statutory services. In 2025, both parents, Constance Marten and Mark Gordon, were convicted of gross negligence manslaughter, child cruelty, perverting the course of justice, and concealing the birth of a child. We share these facts to inform, not to sensationalise, and to help us all understand what stronger safeguarding could look like.

So, who is making these recommendations? The national Child Safeguarding Practice Review Panel is an independent body set up in July 2018. It brings together experts from social care, policing, health, education and the voluntary sector to review serious child safeguarding incidents and to spot patterns that local services might miss on their own.

Why this matters is clear in the numbers. Department for Education data published on 18 December 2025 shows that on 31 March 2025 there were 1,430 unborn infants and 3,930 children under one on child protection plans in England. The Panel’s Annual Report 2023 to 2024 records that children under one account for 36% of serious incident notifications; this rises to 44% when counting children under two in the 2022 to 2023 report. Infants are, tragically, the age group with the highest fatality rate.

The review says the circumstances of baby Victoria’s death were rare, but the risk factors around her family were not. Practitioners saw a repeating picture of several concealed pregnancies, earlier child removals, domestic abuse, limited engagement with services, serious offending and frequent moves across local areas. Agencies often knew parts of this story but did not always assess and manage the risks together. The Panel concludes the death was not predictable; however, given the history, professionals needed to think ahead, consider safety before conception, and coordinate efforts much earlier.

Let’s pause on pre-birth safeguarding. When risks are high, professionals can assess a pregnancy and plan support and safety measures before the baby is born. The Panel calls for national guidance that explicitly includes unborn babies and infants in child protection frameworks, with clear protocols for concealed or late-disclosed pregnancies. This would help midwives, health visitors, GPs, social workers and police work from the same expectations.

Here’s what trauma-informed practice means. Some parents avoid services because of grief after previous child removals, fear of stigma, domestic abuse, substance use or mental ill-health. A trauma-informed approach asks what has happened to someone, not what is wrong with them, and builds trust over time. The Panel argues that this is essential if we want to reach families who disengage and reduce the chance of harm repeating.

The review also urges better engagement with and support for parents before and after a child is removed. Without help, pain and shame can push people away from services, raising risks in future pregnancies. Support that combines practical help with therapeutic work can make it easier to stabilise housing, address abusive relationships and attend treatment-key steps in breaking cycles of harm.

A ‘Think Family’ approach brings adult and children’s services together so professionals see the whole household. That includes strong links with offender management when a parent is a serious sex offender, and close coordination with domestic abuse, mental health and substance use services. A shared chronology of key events helps teams understand patterns, especially when families move between local authorities.

Moving home should not mean starting again from scratch. The Panel calls for clear handovers when families relocate: formal transfer of information, an agreed safeguarding lead and up-to-date contact details. It also stresses that professionals need time, supervision and training to manage complex risk well; the national system must give them the capacity to do this.

So what does this mean for practice today? If you work with families, the message is to think earlier and to work together. Name the risks, plan for the pregnancy, share information lawfully and purposefully, and keep trying to engage parents with curiosity and respect. If you are studying social work, midwifery or policing, notice how these recommendations translate into everyday routines: ask about history, record chronologies and agree who is leading.

If these terms are new, here is a quick guide. A child protection plan is a formal, multi-agency agreement to keep a child safe and to support parents to reduce risk. Concealed pregnancy means a pregnancy known only late in gestation or kept hidden. Multi-agency working means different services acting together with a single plan rather than in parallel.

Panel Chair Sir David Holmes CBE says we cannot prevent every act of extreme parental harm, but we can reduce risks and help families move forward. The takeaway for all of us is simple but demanding: protect babies by supporting their parents and coordinating services earlier. If you are worried about a child, contact your local authority children’s services; in an emergency, call 999.