Source · Prevention of Future Deaths
Lily-Mai George
Ref: 2021-0033
Date: 10 Feb 2021
Coroner: Mary Hassell
Area: Inner North London
Responses identified: 0 / 1
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Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
Date
10 Feb 2021
56-day deadline
7 Apr 2021 est.
Responses identified
0 of 1
Coroner's concerns
Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
View full coroner's concerns
Many healthcare and other professionals expressed the view that Lily-Mai should not be discharged into the unsupervised care of her parents, but Haringey Children’s Services nevertheless facilitated that discharge from hospital on Thursday, 25 January 2018. Lily-Mai suffered her fatal injuries six days later.
A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit, with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made.
If you have not done so already, I encourage you to listen to the recording of the inquest so that you have a starting point for consideration of the actions and omissions of Haringey Children’s Services.
A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit, with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made.
If you have not done so already, I encourage you to listen to the recording of the inquest so that you have a starting point for consideration of the actions and omissions of Haringey Children’s Services.
Report sections
Investigation and inquest
On 19 April 2018, I commenced an investigation into the death of Lily-Mai Hurrell Saint George, aged 10 weeks. Following a lengthy police investigation, the coronial investigation concluded at the end of the inquest on 8 February 2021. I made a determination at inquest that Lily-Mai had been unlawfully killed.
Circumstances of the death
Lilly-Mai was hurt by an adult with such force that she suffered 19 rib fractures, other broken bones, and a severe head injury from which she died. This took place on the afternoon/evening of Wednesday, 31 January 2018, while she was in the exclusive care of her parents.
Copies sent to
Haringey Safeguarding Children BoardHaringey Child Death Overview PanelBarnet HospitalCare Quality Commission for England
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Continuing community support provision
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Prevent discharge of hospitalised children with concerns until home is safe
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Require consultant or paediatrician permission for discharging children with protection concerns.
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Require documented future care plan for discharging children with protection concerns.
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Ensure identified GP for children with deliberate harm concerns discharged from hospital.
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Remind professionals of their role in identifying and reporting child abuse
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Advise police on absconders from care homes and social worker consultation
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Require reporting of absconsions to social worker and independent follow-up
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Single agency for high-risk children
Report details
- Reference
- 2021-0033
- Date of report
- 10 February 2021
- Coroner
- Mary Hassell
- Coroner area
- Inner North London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Apr 2021 (estimated).
Sent to
- Children’s Services, Haringey Council