England’s Children’s Commissioner has branded the “harrowing” death of baby Preston Davey at the hands of his adoptive father “a failure of the state and the safeguarding system”.
Dame Rachel de Souza said a safeguarding review must find out “whether we could have prevented Preston’s murder” and the Government has pledged to ensure “anyone responsible for negligence faces consequences”.
A local child safeguarding practice review (LCSPR), launched by Oldham Council after the child’s death, will look at whether there were any missed opportunities to spot issues with his care while he was alive.
Such reviews are carried out after the death or serious injury of a child where abuse or neglect are known or suspected to be a factor and they consider the work of all agencies involved including police, health, social care and education.
The national child safeguarding practice review panel – which considers the most serious incidents of child abuse and neglect to identify what can be learned – will work with the local review into Preston’s death “to get to the bottom of this horrifying case”, the Government said.
The trial of Jamie Varley, convicted of the murder and sexual abuse of his adopted 13-month-old baby, heard Preston had been taken to hospital three times, was seen by a “battery of professionals” and that police had even been called in the weeks before his death.
Former schoolteacher Varley was sentenced to a whole life order on Thursday while his partner, ex-public schoolboy and sales manager John McGowan-Fazakerley, was jailed for 25 years for allowing Preston’s death.
Both had sexually assaulted and physically abused Preston after adopting him aged nine months and were convicted by a jury following an eight-week trial at Preston Crown Court.
Dame Rachel branded the case “truly harrowing” involving “unimaginable cruelty”.
She said: “I am clear that this is a failure of the state and the safeguarding system. The state decided Preston couldn’t be kept safe by his birth family, took responsibility for securing him a safer future, and this child has been murdered.
“I have a responsibility to challenge the system and will not stop until I find out what has happened.
“We know that in his short life Preston went to A&E multiple times, the police were called and a social worker visited. The judge said that professionals were reassured by his killer’s profession and manner. I need to know whether we could have prevented Preston’s murder.”
Referencing previous child deaths involving safeguarding failures, she added: “We have been here too many times. Arthur Labinjo-Hughes, Star Hobson and Sara Sharif are names we should never forget.
“I come back to the same point: we need professional curiosity across the child protection system. We need a system that promotes working together, information sharing, accountability and, crucially, learning lessons.”
A safeguarding review in November 2025 found murdered 10-year-old Sara was “failed by the safeguarding system” in multiple ways throughout her short life and found that her father’s domestic abuse had been overlooked and underestimated.
The report into numerous missed opportunities concluded that while a “great deal of information” was available to various authorities, even safeguarding professionals appeared to have been “groomed and manipulated” by her killer father, Urfan Sharif.
Sara, who was found dead in a bunk-bed at the family home in Woking, Surrey, in August 2023, suffered what was described as “horrific abuse” at the hands of Sharif and her stepmother, Beinash Batool.
A review in May 2024 into efforts to safeguard six-year-old Arthur Labinjo-Hughes said it was difficult to understand why police did not step in after being sent a photograph of bruising suggesting he had been “subjected to a brutal assault”.
That report identified three critical missed opportunities involving police and social care within nine days, and said pictures of the child’s injuries sent to the authorities “could and should have changed the course of this case”.
Arthur was murdered by his stepmother Emma Tustin at their home in Cranmore Road, Solihull, in June 2020 after being poisoned, starved and beaten.
Star was murdered by her mother’s girlfriend at her home in Keighley, West Yorkshire, in September 2020. Star’s mother Frankie Smith, 20, was found guilty of causing or allowing the youngster’s death.
An explanation that concern from a family member might have been malicious and rooted in a dislike of her mother’s same-sex relationship was “too easily accepted”, a review into the child’s death found.
It also said Bradford children’s social care service was “in turmoil” in 2020, with a high turnover of social workers and a high volume of work affecting quality and contributing to assessments that were “too superficial” and did not address repeated concerns from family members.
The Government described Preston’s abuse and death as “sickening” and recognised the “public rightly demand answers about what went wrong”.
It said it had had “brought in the most far-reaching child protection reforms in a generation, including with a new law, the Children’s Wellbeing and Schools Act, which requires social workers, health professionals and the police to work together better to protect vulnerable children at risk of abuse”.
In December it announced it would establish a new Child Protection Authority (CPA) in England “to oversee the national picture”.
Speaking at the time, children’s minister Josh MacAlister said that authority would “absorb and build on the impressive work” of the current national review panel.
The establishment of a CPA was one of 20 recommendations made by Professor Alexis Jay in her final report in 2022 from the Independent Inquiry into Child Sexual Abuse (IICSA)
Mr MacAlister said the Government wants to “build a more expert, decisive and focused child protection system” in the wake of problems which he said had “allowed abuse and exploitation to go unchecked”.
No firm date has been given yet for when the CPA will be established but Dame Rachel said it must “be brought in without delay”.
An Oldham Council spokesperson said baby Preston’s case had been “particularly heart-wrenching and disturbing” and confirmed the local independent CSPR “will examine the handling of Preston’s safeguarding”.
