A review into how an 11-month-old baby was left to starve to death reveals a
health visitor expressed grave concerns about the family to Social Services.
Neil and Alison Baker, of Hunsdon Close, Walcot, were jailed for five years in
March after admitting the manslaughter of their baby Kimberley.
As reported at the time Kimberley was described as looking like a
famine-ravished Third World child in court.
A report out today from the Swindon Local Safeguarding Children Board shows that
although many of the indicators of neglect were apparent, the main input of
Health and Social Services seemed to focus on the mother's health and general
family support' rather than the well being of Kimberley.
It continues: "It is possible that the focus was on the mother's and children's
health rather than identifying child protection concerns."
The 16-page review outlines 20 recommendations to the agencies who encountered
the family, including Social Services and Swindon and Marlborough NHS Trust.
It says there were a number of missed opportunities for Social Services to
intervene and assess the situation.
Kimberley was last seen alive by health workers in September 2004 when she was
doing well. She died in April 2005.
The report, chaired by Julie Downey, head of Safeguarding for Children Services,
said: "It is of significant concern that such a young child, with a family
background of feeding problems, maternal depression and domestic violence
incidents, was not seen by any professionals between then and the time she
died."
The report also shows how concerns of the health visitor, probation officer, GPs
and hospital doctors were noted, reported, passed on to each other informally
but not followed up.
Had they been, the report says, it would have had the effect of highlighting the
collected concerns of the professionals, and raising the profile of the case.
The review shows there was also uncertainty on who should take the lead in
coordinating the concerns when they arose.
There were occasions in 2001 and 2002 when neighbours reported worries about the
children to the police and health professionals.
It was in April 2002 that a health visitor expressed grave concerns about the
family to Social Services.
But it was six months before the first and only visit from a social worker and
no interventions were made beyond support for a housing application and help for
the mother to get more rest, the review said.
The report shows that other health professionals made a number of visits to the
family home but were unable to make contact.
Yet these failed visits were not flagged up with the relevant line manager.
In April 2005, the month of Kimberley's death, a health visitor found the home
was dark, smelly and sparsely furnished.
Kimberley died before discussions with the family about a referral to the Local
Preventative Group were due to take place.
The 11-month-old baby weighed just 4.6kg when she died- the average weight of a
six-week-old baby.
Sentencing the couple to five years each, Mr Justice John Royce described
Kimberley as a "pitiful, seriously emaciated mite" and said photographs of her
dead body were "truly shocking".
"Her chance of a decent life or any life in this world had been snuffed out by
the appalling negligence of you two," he told the couple.
"Had you gone to seek expert advice it may very well be that Kimberley lived.
Instead you decided to save your own skins."
Dr Hugh White, who carried out the post mortem examination, said the cause of
death was starvation, dehydration and neglect.
The couple claimed Kimberley had not been eating for two weeks but Dr White said
his findings were not consistent with this claim and it looked a significantly
longer period of neglect and inadequate nourishment.
Neil, 29, and Alison, 25, had four other children who have all been taken into
care.
