Local authorities and police criticised after failings contribute to the deaths of two babies

One thing, which is seldom appreciated by those working outside the field of child protection, is that, ultimately, if you make the wrong decision, a child may die. The tragic reality of this is illustrated by two recent inquests.

Alfie Gildea was just four months old when he died on 14 September 2018 as a result of head injuries sustained when he was subjected to violent shaking by his father two days earlier. On 18 November 2020, Alison Mutch, the Senior Coroner for Greater Manchester South, submitted a report, following the conclusion of the inquest into his death, detailing her concerns about multiple failings by the police, the Crown Prosecution Service, Children’s Services and the Health Visitor Service.

Alfie’s father, Sam Gildea, was described as a ‘serious and serial domestic abuse perpetrator’. He had 20 previous convictions, including six for domestic violence involving his previous three partners. He went on to form a new relationship with Caitlin McMichael. Greater Manchester Police were called to the family home following an allegation of verbal domestic abuse by Gildea towards Caitlin McMichael. The officers failed to recognise that Gildea was a serious and serial domestic abuse perpetrator and so did not consider using the ‘Right to Know’ provisions of the Domestic Violence Disclosure Scheme (DVDS) to inform Ms McMichael of her partner’s previous convictions. Alfie’s mother would later tell the coroner that she only learned of these convictions after the child’s death.

On 15 March 2018, the father was assessed by a psychiatrist as having a ‘split personality disorder’ and the psychiatrist recommended additional support from services such as the Health Visitor Service after Alfie’s birth. Not only was this information not shared with the Health Visitor Service, but the assessment itself was also deficient as the psychiatrist only had an incomplete risk assessment and did not have any information about Gildea’s history of domestic abuse because the information provided by the police was incomplete. In her regulation 28 report, the coroner states that ‘as a result, the clinician carrying out the assessment did not fully understand the safeguarding risks’.

The police were called to the family home again on 10 July 2018 after a further report of domestic abuse. According to the coroner’s report, the officers:

• failed to identify Gildea as a serious and serial domestic abuse perpetrator
• failed to assess the level of risk correctly
• failed to recognise that the details they were being given suggested a coercive and controlling relationship and
• failed to consider appropriately the application of the DVDS.

The police informed Trafford Metropolitan Borough Council’s Children’s Services Department the following day, but the local authority did not review all of the material sent to them and so did not correctly identify the level of risk posed by the child’s father. The case was closed without any effective communication with other agencies and without any further investigation into the risks to the child. The Health Visitor Service was also informed about the incident, but did not make an accurate assessment of the level of risk and did not effectively engage with Alfie’s mother.

In breach of its own policies and guidance relating to domestic abuse, the Crown Prosecution Service decided to take no further action about the events of 10 July 2018. The coroner found that the CPS made that decision without proper consideration of how the case could be built and what further lines of enquiry could be directed. It appears that the police did obtain a domestic violence prevention order from the court which prevented Gildea from seeing Alfie’s mother for 28 days, but this order expired without her obtaining any longer-term protective measure such as a non-molestation order or occupation order.

Nine days after the expiry of the DVPO, the police were again called to the family home after a further incident. On this occasion, the police dealt with the complaint as a matter of taking a motor vehicle (presumably Ms McMichael’s) without the owner’s consent and again failed to recognise that this was further evidence of Gildea’s coercive and controlling behaviour towards Alfie’s mother. The coroner records that the officer attending did not fully explore with Alfie’s mother what she actually knew about her partner’s previous history of domestic abuse and again failed to identify Sam Gildea as a serial and serious domestic abuse perpetrator. The context of the incident was not sufficiently considered and, as a result, the level of risk was not properly assessed or communicated.

The police informed Children’s Services of the latest incident the following day, but they too failed to make an accurate assessment of all of the information which they had available to them and so they did not recognise the level of risk and did not tell Alfie’s mother about this. Similar information was given to the Health Visitor Team, who, similarly, failed to act on this or to communicate with the mother about the true level of risk to her and her baby.

On 12 September 2018, whilst Alfie was in his father’s care, he was violently shaken, causing the injuries from which he died two days later. The child’s father was charged with his murder, but a plea of guilty to manslaughter and coercive and controlling behaviour was accepted by the prosecution. Gildea is serving a prison sentence of 15 years for these two offences.

At the conclusion of the inquest, the coroner listed 15 separate matters of concern. The evidence at the inquest had shown that ‘it was unclear’ where information identifying an individual as a serial and serious domestic abuse perpetrator should be located. There was a lack of understanding amongst officers about what Greater Manchester Police’s policy on serial/serious domestic abusers was and the actions required of them under those policies. Most officers had received only very limited training in domestic abuse and particularly about coercive and controlling behaviour.

The coroner criticised the poor information sharing between the police and the local authority, as a result of which there was no holistic overview of the situation or the risk posed by Alfie’s father. Opportunities to use the MARAC framework were not taken. The MARAC was significantly under-resourced, as an Ofsted inspection had subsequently confirmed. Staff who were not qualified social workers were making key decisions because the staff were over-stretched.

Alison Mutch also found a limited understanding of coercive and controlling behaviour in the Health Visiting Service, which was increasingly stretched due to national funding arrangements. Conversations, which policy required should take place face-to-face, took place by telephone and questions about whether the victim was subjected to domestic abuse took place ‘when the perpetrator was in close proximity and allowed little real opportunity for disclosure’.

On 8 February 2021, Haringey Council’s Children’s Services Department was the subject of significant criticism at the conclusion of an inquest at St Pancras Coroner’s Court into the death of 10-week old Lily-Mai Hurrell Saint George on 2 February 2018. Lily-Mai was born prematurely and spent the first two months of her life in Barnet Hospital. At a discharge meeting on 22 January 2018, the healthcare professionals all expressed concerns about the child’s safety because of concerns about the mother’s bonding and attachment with Lily-Mai. The parents had not visited or checked on the baby’s health for three or four days. Sithembile Dzingai, the locality manager responsible for allocating health visitors, told the coroner:

‘In my 12 years as a health visitor, I’ve never had such a feeling of anxiety as I did about Lily-Mai being discharged in this way because there were a number of concerns.’

Despite these warnings, Haringey Children’s Services facilitated Lily-Mai’s discharge from the hospital into the care of her parents on 25 January 2018. Ms Dzingai told the inquest that she worried that there was ‘no robust plan in place to support the parents’.

A health visitor, Alberta Nyantakyi, visited the family after Lily-Mai had been discharged. Replying to questions from Senior Coroner Mary Hassell, she said that she did not feel that the baby was safe with her parents. She contacted Haringey social worker Theresa Ferguson to report her concerns and to say that she did not think that the decision to discharge Lily-Mai to the care of her parents had been correct.

Haringey Children’s Services arranged for a legal gateway meeting to take place with the parents on 31 January 2018 where it was agreed that the parents and the baby would go into a mother and baby placement but Lily-Mai would remain in her parents’ care until then. That evening, the baby was found unresponsive at home and taken to Great Ormond Street Hospital, where she died two days later. She had suffered 19 rib fractures and a severe head injury. She had also sustained a forceful traction and twisting injury to her leg. When asked by the coroner whether she felt Lily-Mai was safe being left in her parents’ care, Theresa Ferguson said that whilst she was ‘really worried about her’, she ‘didn’t think there would be immediate harm’.

The coroner returned a verdict of unlawful killing. Although Lily-Mai was in the sole care of her parents when she sustained the fatal injuries, the Metropolitan Police were unable to charge either parent as the evidence did not establish whether she was injured by one individual or by both.