The review was launched following the tragic death of baby Victoria Marten in early 2023 after her parents, Constance Marten and Mark Gordon, concealed her birth and deliberately evaded statutory services.

Marten and Gordon were convicted of gross negligence manslaughter, child cruelty, perverting the course of justice and concealing the birth of a child.

The review concluded 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.

The report called on Government to act urgently to strengthen national guidance, improve information‑sharing between agencies and ensure professionals have the time, skills and support needed to safeguard unborn babies and infants effectively.

Over 5,000 unborn babies and infants under the age of one were subject to child protection plans last year.

Panel chair, Sir David Holmes, said: ‘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.'