A serious case review into the death of four-year-old Naomi Hill, who was drowned in the bath by her mother in 2007, has concluded that there were “no serious failings” by agencies.
Naomi, who had mild cerebral palsy, was killed by her mother, Joanne Hill, after Hill suffered a serious relapse of a depressive illness.
However, a psychiatric assessment following the tragedy found that Hill did not have a psychotic condition at the time.
Mother convicted of murder
She pleaded guilty to manslaughter on the grounds of diminished responsibility at a trial held last year, but was convicted of murder and sentenced to a minimum jail term of 15 years.
A serious case review by Flintshire Local Safeguarding Children Board, published yesterday, examined the contact between the Hill family and mental health, education, health and antenatal services.
Murder not predictable
It found that there were no signs that Naomi was at risk and that her death was not predictable. It also concluded that there were “too many imponderables” to consider whether her death was preventable or not.
The review said: “In many ways this family received good service provision. As authors we were impressed with the dedication and care shown by all the staff who we interviewed. Case records were full, all meetings were conducted to schedule and promises made were kept.”
Response to disability had no bearing on killing
The authors also found that Naomi’s disability, which was described as “very mild”, and Hill’s response to it had no bearing on the incident. Hill was said to have a good relationship to her daughter when she was in good mental health.
In addition, the review said that there was no evidence to suggest Hill’s increased alcohol intake at the time of the incident was outside her normal behaviour patterns.
Carers should have been more involved
Despite the praise, the review said that as Joanne’s carers, Naomi’s father – Simon Hill – and grandmother should have been more involved by mental health workers.
A series of recommendations included for mental health services to develop a carer’s plan and to name one clear point of contact for patients and their carers.
It also recommended that midwifery services give greater consideration to mental health issues.
Services ‘must not be complacent’
Susan Lewis, chair of Flintshire LSCB and director of community services at Flintshire County Council, said that although the review found no serious failings, services should not be complacent. She added: “This is part of the climate of constant vigilance which must be maintained by all agencies which are part of Flintshire’s LSCB.
“Accordingly, the authors have recommended, and we have accepted, a range of recommendations which we have already started to pursue in advance of this publication.”
Joanne Hill’s history of mental illness
The serious case review found that Hill was prone to bouts of severe depression brought on by stress since being first referred to a psychiatrist in 1993 aged 17. After Naomi was born prematurely in June 2003 her mental state deteriorated, but she recovered and the family lived “reasonably happily together”.
Then in January 2006 Naomi was diagnosed with cerebral palsy and had to wear callipers to help her walk. In the following year Hill again suffered a serious relapse and was referred to the crisis resolution and home treatment team. During this time her relationship with her husband began to suffer and concerns were raised about her drinking.
She was then transferred to the community mental health ream before being discharged in the summer of 2007. The review said that the action taken was appropriate as she had a history of recovering quickly from severe relapses.
Hill killed Naomi on 26 November 2007 by forcibly holding her under water in the bath at the family home in Connah’s Quay, north Wales.