Professionals involved with the family of the Kettering baby girl murdered at the hands of her mother’s boyfriend failed to detect that she was being neglected.
On a number of occasions information that should have been shared between health professionals, the police and social services was not.
The baby’s life support was turned off on April last year, three days after being admitted to hospital after her mother had called an ambulance when she returned home to find her daughter pale, floppy and not breathing.
The mother’s partner, Ryan Coleman, who had been living in the house and looking after the baby while her mother was at work, said she had fallen off a bed.
In February this year he was convicted of murder and sentenced to life in prison.
The court found he had carried out a violent assault on the child and inflicted 31 injuries.
The serious case review - which refers to the baby as child Ap and Coleman as Mr X - found that “that no individual agency could have foreseen or prevented the death of child Ap.”
But it did find that “None of the agencies involved with Mr X whilst he was living with mother made an assessment of or gave consideration to the risk he may have presented.”
The family had been well known to the authorities and a child protection order had been put in place because of the emotional impact of domestic abuse carried out by the violent father on the mother over a number of years.
Mr X, who had criminal convictions and was a drug dealer, had moved in with the family in May 2017, shortly after meeting the mother through social media and when the baby was one month old.
The children’s father was in prison.
The review ‘ identified several areas of weakness among the agencies involved’.
It says it was evident the medical records contained a significant amount of information, which would indicate neglect, but this was not communicated to children’s social care’.
The baby had been admitted to hospital three months before her death after having fits and had found to have pneumonia and a collapsed lung.
The review found ‘it is surprising that the possibility of neglect as being a concern was not considered’.
The health visiting service had said that the care of the mother was good.
Social services is criticised for the period from when it was involved with the family from 2016. After child protection plans were put in place due to the domestic violence, there was a lack of visits because their first allocated social worker was off sick. The second social worker did not progress plans or challenge the mother for not engaging. The child protection plan was then stepped down to a lower risk category despite the visits not having taken place
Because of the father’s criminal past and the domestic violence carried out by the father, the family was well known to police. However the review found there had been a ‘missed opportunity by the police’.
In June 2017 a police protection notice should have been submitted to children’s social care after information about Mr X living at the address was received. Later on information about Mr X’s drug dealing was passed to the multi-agency safeguarding hub (MASH) but no further action was taken as it was not seen as critical.
The police’s involvement at the time of the incident in April 2018 and in the following days also featured ‘several missed opportunities’.
The bedroom was classed as the crime scene and investigators did not keep an open mind as to where else in the house the baby may have been injured. The child’s injuries were also not photographed on the first day of her admission to hospital.
The review did find examples of good practice in that a serious crime review was carried out within hours of the injury and further lines of enquiry were identified.
Director of Children’s Services Sally Hodges said: “We are deeply sorry for the poor decision making and the mistakes which were made in the events leading up to this tragedy.
“The report makes it clear that across the board, many public services in Northamptonshire missed a number of opportunities to raise concerns about this family and it is our duty to work together to minimise the chance of these
mistakes being made again.
“There is simply no excuse that agencies failed to share information amongst each other which if put together earlier would have led to a far more realistic
picture of the risks this child was facing. For our part in this failure and for the poor decisions made within social care we are truly sorry. We let this child down.
“The Government announced last month that Children’s Services will be moving into a Trust. This is an opportunity to accelerate the improvements already under way and introduce better working practices across the whole of children’s services and amongst our partners.”