Marten and Gordon had five children together, four of whom were taken into care prior to the birth of baby Victoria.
Family court documents show how over the years the couple moved around the country to avoid contact with social services when Marten was pregnant, refused antenatal and newborn healthcare and repeatedly missed contact sessions with their children once they were in care.
Given the repeating pattern of concealed pregnancies and child removals in the family, the authorities should have anticipated another pregnancy was likely, the review found.
Had authorities known earlier that her parents were expecting another child, more could have been done to save baby Victoria.
There is no legal duty for a woman to disclose her pregnancy. The report suggested social services would have had an earlier opportunity to intervene had Gordon, a registered sex offender, been required to share details of his partner’s pregnancy with the authorities.
The review also suggested better support was needed for parents whose children are taken into care.
No single agency or professional had specific responsibility for supporting the couple when their children were removed, or “helping them process their likely sense of loss and grief”, the review found.
It suggested the “successive removal” of Marten and Gordon’s children “may have reinforced their perception of harm caused by children’s social care, making the concealment of Victoria feel subjectively ‘rational”‘.
Marten, who provided written responses to questions from the panel, said that the impact on parents of having a child removed is not properly understood.
She described seeing her children at a contact centre as “one of the most painful experiences for a parent to endure”.
More than 1,400 unborn infants were subject to child protection plans (CPPs) on 31 March 2025, while around 3,930 children aged under one were subject to CPPs on the same date, the report said.
The review said agencies such as health and housing authorities needed to work together more effectively to help women who present a high risk to their children.
Domestic abuse, Gordon’s criminal past, and the parent’s refusal to engage with authorities, as well as multiple moves around the country, were among the challenges the authorities faced in protecting the couple’s children.
A press release published by the panel said better communication with Marten and Gordon, as well as “earlier coordinated action” from the authorities, “might have made a difference” in baby Victoria’s case.