Health and social care professionals missed chances to prevent the death of an 11-month-old baby who was murdered by his mother, a serious case review has found.
The investigation into the death of Callum Wilson found that in the fortnight before his death in March 2011 bruising was noticed three times, but none of these incidents were reported to the local authority.
Scratches and bruises were also noticed by other medical and care professionals in earlier weeks, but again these were not reported to social services, according to the report by the Windsor and Maidenhead local safeguarding children board.
Had the injuries been noticed, the baby could have been referred to a child protection medical examination, the report stated. This would have included x-rays, which would have been likely to reveal fractures that were at least two weeks old.
The fractures were discovered along with bruises on his face, head, chest, back and legs when we was taken to hospital with the very serious head injury which killed him.
The report also said the risks to the baby were underestimated and that he should have been closely monitored when he moved from foster care to live with his mother.
She had failed to visit him for long periods when he was in care for nearly seven months. Additionally, she concealed her pregnancies before giving birth to both him and his older brother, which should have prompted closer monitoring. However the council carried out two visits after he went to live his mother and then closed its case.
Some professionals also accepted his mother’s explanation that the scratches and bruises had been caused by his brother, who was nearly two years old.
The report said communications between health staff did not make it clear that the mother had concealed her two pregnancies, which contributed to GPs and health visitors who noticed bruising not recognising the risks in the case. Additionally some professionals involved were not aware that the baby had been a looked after child.
The report also found failures in communication and information sharing between professionals, the design of the personal child health record, and in training.
It also highlighted an overstretched health visiting service and delays in transferring GP records which made the system “not fit for purpose” for vulnerable children.
The case had been wrongly deemed straightforward, the report stated, and so was given an inexperienced social worker who was not adequately supervised.
The baby’s mother, Emma Wilson, was convicted of his murder in December and sentenced to life imprisonment with a minimum term of 14 years in January.
In a joint statement, the Royal Borough of Windsor and Maidenhead, Berkshire Healthcare NHS Foundation Trust, Windsor, Ascot & Maidenhead Clinical Commissioning Group, and Heatherwood and Wexham Park Hospitals Trust, said all of the report’s recommendations had been implemented for some time and procedures had been strengthened beyond them.
It said it had improved policies and procedures on concealed pregnancies and on formal reporting of bruising in very young children.
“We can never guarantee the total safely of every child who comes into our care or seeks our help,” the statement said.
“However, we can work to ensure that, as far as possible, the mistakes made in Callum’s case will not be repeated and that staff are given all the necessary support, training and guidance to enable them to deliver the service that every child deserves.”