England’s national Child Safeguarding Practice Review Panel has called for earlier and stronger pre‑birth safeguarding, tighter multi‑agency coordination and clearer national guidance for unborn babies and infants. The conclusions follow its review of baby Victoria’s death, after her parents concealed the birth and evaded statutory services.
Baby Victoria was born in December 2022 and died in early 2023. In 2025, her parents, Constance Marten and Mark Gordon, were convicted of gross negligence manslaughter, child cruelty, perverting the course of justice and concealing a birth. The Panel notes that while such outcomes are rare, the professional challenges exposed are familiar across serious safeguarding incidents.
The review identifies a pattern of risks in the family history: several concealed pregnancies, repeated removals of older children, domestic abuse, minimal engagement with services, serious offending and frequent moves between local areas. It finds that agencies often record these risks in isolation rather than assess and manage them together.
Department for Education statistics published on 18 December 2025 show that, as at 31 March 2025, 1,430 unborn infants and 3,930 children aged under one were subject to child protection plans. The Panel frames this as both a concentration of risk and an opportunity for earlier, constructive intervention.
Although baby Victoria’s death was not predictable, the review concludes that the history of concealed pregnancies and prior removals should have prompted professionals to anticipate risk before conception and plan for safety sooner. Earlier, coordinated engagement with both parents may have altered the outcome.
The report calls for national guidance to state explicitly how vulnerable unborn babies and infants sit within child protection frameworks. It seeks clearer, standardised protocols for concealed or late‑disclosed pregnancies, with defined triggers for pre‑birth assessment and multi‑agency planning.
A shift towards trauma‑informed practice is recommended to reach families who disengage. According to the Panel, avoidance often reflects grief or mistrust-particularly after previous removals-rather than deliberate refusal. Practitioners need time and supervision to address underlying drivers such as domestic abuse, substance use and mental ill‑health.
The review urges better engagement with parents before and after removal decisions to break cycles of harm. A preventative ‘Think Family’ approach should connect adult services-including probation, mental health and substance misuse support-with children’s social care, maternity and health visiting to form a single view of risk.
Where a parent or carer is a serious sexual or violent offender, the Panel expects closer ties between children’s social care and offender management services so that risk assessment and safety planning are aligned and up to date.
Frequent movement between areas was a defining feature in this case. The Panel recommends formal information transfer, shared chronologies and clear lines of safeguarding responsibility whenever families relocate, to prevent loss of oversight as cases cross boundaries.
Panel annual reports underline the urgency: 36% of serious incident notifications relate to children under one; extending the age range to under two raises the figure to 44%. Infants under one notified to the Panel represent the age group with the highest fatality rate, reinforcing the need for pre‑birth focus.
For local safeguarding partnerships, the operational implications are immediate. Update concealed‑pregnancy procedures, strengthen pre‑birth conferences for high‑risk cases, test information‑sharing pathways across maternity, general practice, health visiting, police and probation, and maintain clear accountability when families move.
The Panel also stresses workforce conditions. Effective safeguarding requires time, skills and support; without capacity for sustained engagement and reflective supervision, contact risks becoming transactional and missing cumulative harm.
The government is asked to act at pace to strengthen national guidance and improve information‑sharing. The Panel’s message is that many improvements can begin within existing statutory duties while ministers consider the report’s recommendations.