The tragic and horrific case of Baby Peter, the toddler who died in August 2007 after receiving sustained abuse from his mother, her boyfriend and their lodger, provides a stark reminder of the importance of communication at work and the potential consequences of getting it wrong.

The Care Quality Commission released its report on the role of the NHS in this case. It is broad in its range and highlights a number of systemic failings, some of which relate specifically to communication.

Two of the six themes or topics investigated by the CQC jump out for me - lack of communication and lack of awareness of child protection procedures. These are covered in detail in the report, but the key deficiencies were described by the CQC as:

- Poor communication between health professionals and between agencies, leading to a lack of urgent action with regard to child protection arrangements, and no effective escalation of concerns.
- Lack of awareness among some staff about child protection procedures, and a lack of adherence, by some staff, to these procedures.

What lies behind this is a range of issues relating to ineffective organisational communication. These issues range from straight-forward communication breakdowns where groups who should be talking to each other aren't, problems with the visibility and access of some of the key players (they were on the road, rather than on the ground), healthcare professionals failing to turn up to vitally important case conferences, basic processes that were either broken or inconsistently implemented (like writing up and circulating the minutes from case conferences and following-up a child protection referral), steering groups and boards that were described as 'closed off' and uncommunicative and patchy employee understanding of policy and procedure.

These areas may be operational and therefore outside the typical remit of the internal communicator, but I believe these are precisely the sort of challenges we should be grappling with - ensuring managers and front line staff interact in the right way, taking the pulse of the organization and providing an early warning of any issues, building awareness and understanding of key policies, making sure leaders are accessible and visible, engaging diverse stakeholder groups. Internal communication is not 'soft and fluffy' - it is at the very heart of the organization, whatever its purpose, and is critical to its effective functioning.

These communication issues are, of course, not unique to the organisations involved here - they are pretty commonplace - but the consequences in this example were on a whole different level. A tragedy in so many ways, let's hope the lessons really will be learned this time around.