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A national child safeguarding review has urged immediate reform to improve the protection of vulnerable unborn babies and infants, following the death of baby Victoria Marten and the subsequent criminal convictions of her parents.
The review, published by the Child Safeguarding Practice Review Panel, examines the circumstances surrounding Victoria’s death and identifies wider systemic issues that safeguarding professionals encounter when working with high-risk families. Victoria was born in December 2022 and died in early 2023 after her parents, Constance Marten and Mark Gordon, concealed her birth and deliberately avoided contact with statutory services. In 2025, both parents were convicted of gross negligence manslaughter, child cruelty, perverting the course of justice and concealing the birth of a child.
Although the panel acknowledged that the specific circumstances of Victoria’s death were rare, it concluded that the safeguarding challenges presented by the case are frequently encountered in professional practice. The review identified a number of recurring risk factors within the family, including multiple concealed pregnancies, repeated removal of children from parental care, domestic abuse, persistent disengagement from services, serious criminal offending and frequent relocation across local authority boundaries. These factors, the panel noted, are commonly present in serious child safeguarding incidents.
The report highlighted that more than 5,000 unborn babies and infants under the age of one were subject to child protection plans in the last year, demonstrating both the scale of risk and the potential opportunity for early intervention. While the review determined that Victoria’s death was not predictable, it concluded that her family history of concealed pregnancies and prior child removals required professionals to adopt a forward-looking safeguarding approach, including assessing potential risks to future children even before conception. The panel suggested that earlier and more coordinated multi-agency engagement with the parents may have reduced risk.
The review recommends the introduction of clearer national guidance to ensure that vulnerable unborn babies and infants are consistently included within child protection frameworks. It calls for strengthened multi-agency working and more robust information-sharing arrangements between professionals and services.
Among its recommendations, the panel emphasised the need for earlier and more comprehensive pre-birth safeguarding measures, including clearer protocols for responding to concealed or late-disclosed pregnancies. It also advocated for the wider adoption of trauma-informed practice, recognising that parents’ avoidance of professional engagement often reflects unresolved trauma, mistrust or grief rather than deliberate refusal to cooperate.
The review further highlighted the importance of providing meaningful support to parents both before and after the removal of children, with the aim of reducing repeated safeguarding concerns and breaking cycles of harm. It also called for a preventative “Think Family” approach, encouraging closer integration between adult and children’s services to enable professionals to assess risks and needs across the entire family unit.
In addition, the panel recommended stronger operational links between children’s social care and offender management services, particularly in cases where serious sexual offenders are parents or carers. It also identified the need for clearer safeguarding arrangements when families move between local authority areas, including formalised information transfer processes, shared chronologies and clearly defined safeguarding responsibilities.
The review found that agencies are frequently aware of multiple risk factors affecting families but do not always assess or manage those risks in a coordinated way. The panel warned that without stronger joint working, opportunities to protect vulnerable unborn babies and infants may continue to be missed.
The report calls on government to take urgent steps to strengthen national safeguarding guidance, improve inter-agency information sharing and ensure professionals are equipped with sufficient time, expertise and resources to work effectively with vulnerable families.
Sir David Holmes CBE, Chair of the panel, described Victoria’s death as a devastating case that underlines the importance of supporting parents as part of effective safeguarding practice. He emphasised that while extreme parental harm cannot always be prevented, strengthening support for families and improving professional coordination can reduce risk and help prevent similar tragedies in future.
