A review into the death of two children killed by their mentally ill mother has concluded there was no single action or judgement that triggered or could have prevented it.
Vivian Gamor, who had been looked-after since the age of 14, killed her children, Antoine, 10, and Keneice, three, during an unsupervised visit in January 2007. She was convicted of manslaughter in August 2007 on grounds of diminished responsibility and detained indefinitely under the Mental Health Act 1983.
A serious case review by the City and Hackney Local Safeguarding Children Board, published today, says: “The cumulative result of agencies’ individual perspectives was that there existed no recognition of a physical risk to the children.”
Gamor, a paranoid schizophrenic, had been sectioned in September 2006 for brandishing a knife and in the months before her detention had repeatedly claimed the children were not hers and cut off one side of her daughter’s hair. She also claimed she was “God’s child”.
But at a discharge meeting the following month, it was agreed that Gamor would re-establish her relationship with her children, and there no concerns they were at risk of physical harm.
The report says: “The observations of all those who saw Ms C following discharge from hospital were consistent in their nature and indicated good recovery from a serious mental illness and positive plans for a future that included those whom by then she acknowledged to be her children.”
No evidence for protective order
It adds that Hackney Children & Young People’s Service neither possessed, nor was provided with, evidence that would have justified an application for or obtaining of, any form of protective order.
But it says that following reports of successful contact visits and Gamor’s plan to have the children live with her, further efforts should have been made to contact the children’s father, Gabriel Ogunkoya, with whom they had been living, to assess the situation before deciding whether to support Gamor’s request for re-housing and close the case.
Gamor began having having weekly day-time contact with the children by November 2006. She killed them a fortnight after overnight contact started.
The report criticises the East London & The City Mental Health Trust for failing to carry out an explicit risk assessment of the physical risks to the children of Gamor’s delusions, the likely increase in any risk following resumption of contact and the significance of a reported incident when she answered the door to her relations holding a large knife.
The report also says that blood tests taken after Gamor was arrested showed that she had not been taking her medication for as many as ten days.
Alan Wood, director of children’s services at Hackney Council, said: “This case highlights how unpredictable mental illness can be, and the dreadful impact it can have on families. It also shows how child protection services and mental health services need to work ever more closely to successfully protect children in the future. “
He added that the report’s recommendations had been implemented.
Serious case report blasted by father
But Ogunkoya, who says he was put under pressure by Gamor to let the children stay overnight and had not been informed that she had been disagnosed with paranoid schizophrenia, criticised the report as “scandalous, inaccurate and insensitive”.
Lawyer Bali Gill said Ogunkoya and his family had waited 17 months for the report. “They had hoped to finally get answers to the questions that have tormented them as to why their children were killed – as part of their quest for justice. Instead they have been served with a 14-page summary of a review that asked the wrong questions, of the wrong people and for the wrong reasons. As such, its minimal recommendations are flawed and it seems of little value.”