A national child safeguarding review has called for urgent, system‑wide reform to better protect vulnerable unborn babies and infants across England and Wales, following the tragic death of baby Victoria Marten.
Baby Victoria was born in December 2022 and died weeks later after her parents concealed her birth and deliberately evaded 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.
While the circumstances of her death were rare, the review warns that the professional and systemic safeguarding challenges present in her case are far more common.
More than 5,000 unborn babies and infants under one were subject to child protection plans last year, highlighting the scale of vulnerability and the urgent need for more coordinated, preventative safeguarding.
Baby Victoria’s family history included multiple concealed pregnancies, repeated child removals, and domestic abuse, as well as serious offending and poor engagement with services.
The review has concluded that although Victoria’s death was not predictable, the repeated warning signs meant professionals needed to be thinking ahead and planning for her safety even before she was conceived.
A stronger focus on early engagement with her parents and coordinated action across agencies “might have made a difference,” the review says.
The report calls on government to urgently strengthen national safeguarding frameworks to ensure unborn babies and infants are consistently considered and prioritiesed within child protection systems.
Major recommendations include:
1. Stronger Pre‑Birth Safeguarding
- Clear national guidance explicitly covering unborn babies and infants
- Better protocols for responding to concealed or late‑disclosed pregnancies
2. Trauma‑Informed Practice
Recognising that avoidance of services often reflects grief, trauma or mistrust, not deliberate refusal.
3. Support for Parents After Child Removal
Helping parents before and after removal to break cycles of harm and reduce repeated risk.
4. A “Think Family” Approach
Closer working between adult services and children’s social care to understand issues affecting the whole household.
5. Stronger Links With Offender Management
Ensuring children’s social care works closely with offender managers, particularly when serious sex offenders are parents or carers.
6. Clear Processes When Families Move
Including formal information transfer, shared chronologies and clarity around who holds safeguarding responsibility.
Sir David Holmes CBE, Chair of the Panel, said:
“Few tragedies are greater than the death of a baby, and baby Victoria’s is all the more devastating because her parents caused it.
“Baby Victoria lived in a family where there had been several concealed pregnancies, repeated child removals, domestic abuse, lack of engagement with services, serious offending and frequent moves. These are risks we see time and again in serious safeguarding incidents, and they are examined in depth in our review.
“While baby Victoria’s death was rare, her status as a vulnerable unborn baby and then a vulnerable infant is not. Last year, more than 5,000 unborn babies and infants under one were on child protection plans. Their parents are struggling, often disengaged from services, and many receive little support.
“A key lesson from baby Victoria’s story is clear: to protect vulnerable babies better, we must support their parents too. That may be hard to hear and hard to understand, but it is essential if we are to stop cycles of harm from repeating. Safeguarding professionals need the time, skills and resources to understand why families disengage and to address the underlying issues - whatever they may be - domestic abuse, substance use, mental health, trauma after previous child removals or anything else.
“That is why we are calling for improved national guidance for safeguarding vulnerable unborn babies and infants, and better support for parents whose children are removed. These changes will help reduce future harm.
“We cannot prevent every act of extreme parental harm - but we can reduce the risks in families and help people to move forward. That must be baby Victoria’s legacy.”
The review has also warned that agencies often hold multiple concerns about a family – such as domestic abuse, past child removals or disengagement – yet fail to assess or manage risks together.
Without stronger coordination, opportunities to protect vulnerable babies can be missed, the report states.
The review has urged ministers to act quickly to strengthen national safeguarding guidance, improve information‑sharing between agencies, and ensure professionals have the skills, time and support needed to safeguard unborn babies and infants.
The report stressed that vulnerable unborn babies represent both significant risk and a major opportunity for early, positive intervention.
Image credit: iStock
