Baby Victoria was born in December 2022 and died in early 2023 after her parents, Constance Marten and Mark Gordon, concealed her birth and deliberately evaded statutory services. In 2025 both of baby Victoria’s 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 baby Victoria’s death are very rare, the review finds that the professional challenges and systemic safeguarding issues involved are much more common. The review highlights multiple risks in baby Victoria’s family circumstances including several concealed pregnancies, repeated child removals, domestic abuse, poor engagement with services, serious offending, and frequent moves between different areas. Many of these issues appear repeatedly in serious safeguarding incidents.
More than 5,000 unborn babies and infants under the age of one were subject to child protection plans last year. Such huge volumes of vulnerable unborn babies and infants, and struggling parents, represent a lot of risk but also a lot of opportunity to intervene positively in family life.
The review concludes that baby Victoria’s death was not predictable but, given the repeating pattern of concealed pregnancies and child removals in the family history, baby Victoria needed professionals to think ahead and consider her safety even before she was conceived. A stronger focus on engaging with her parents and earlier coordinated action across all relevant services might have made a difference.
The review calls for clearer national guidance to ensure vulnerable unborn babies and infants are consistently considered within child protection frameworks, alongside stronger multi‑agency working and improved information‑sharing.
Key findings and recommendations include
- Earlier and stronger pre‑birth safeguarding, including national guidance that explicitly includes vulnerable unborn babies and infants, and clearer protocols for responding to concealed or late‑disclosed pregnancies
- Trauma‑informed practice, to help reach families who do not engage with services, recognising that avoidance of services often reflects grief and mistrust rather than deliberate refusal
- Better engagement with and support for parents before and after child removal, to help break cycles of harm and reduce repeat risk
- A preventative ‘Think Family’ approach, bringing together adult and children’s services to provide a holistic view and identify issues that affect the whole family unit
- Stronger links between children’s social care and offender management services, especially when serious sex offenders are parents or carers
- Clearer arrangements when families move, including formal information transfer, shared chronologies and defined safeguarding responsibility
The review finds that agencies are often aware of multiple risks within families such as domestic abuse or parental disengagement but do not always assess and manage these risks together. It warns that without stronger coordination, opportunities to protect vulnerable unborn babies and infants can be missed.
The report calls on government to act urgently to strengthen national guidance, improve information‑sharing between agencies, and ensure that professionals have the time, skills and support needed to safeguard unborn babies and infants effectively.
Panel Chair, Sir David Holmes CBE 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.”
Notes to Editors
The national Child Safeguarding Practice Review Panel is an independent body that was set up in July 2018 to identify, commission and oversee reviews of serious child safeguarding incidents. It brings together experts from social care, policing, health, education and the third sector to provide a multi-agency view on the deaths and serious harm of children due to abuse and neglect.
1,430 unborn infants and 3,930 children aged under 1 were subject to child protection plans (CPPs) on 31 March 2025. See ‘National time series of child protection plans by initial category of abuse by sex, age and ethnicity’ published by the Department for Education on 18 December 2025.
The Panel’s data indicates that 36% of the notifications it receives relate to children under 1 year of age (Annual Report 2023 to 2024). This figure rises to 44% when the age range is extended to under 2 years (Annual Report 2022 to 2023). Notably, children under 1 who are notified to the Panel represent the age group with the highest fatality rate.
