Source · Prevention of Future Deaths
Lily-Mai George
Ref: 2021-0033
Date: 10 Feb 2021
Coroner: Mary Hassell
Area: Inner North London
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryHaringey Children’s Services facilitated the discharge of Lily-Mai into her parents' unsupervised care despite professional opposition. A subsequent decision for residential placement was not implemented before she suffered fatal injuries.
Date
10 Feb 2021
56-day deadline
7 Apr 2021 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
Haringey Children’s Services facilitated the discharge of Lily-Mai into her parents' unsupervised care despite professional opposition. A subsequent decision for residential placement was not implemented before she suffered fatal injuries.
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
Similar PFD reports
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 from the report date).
Sent to
- Children’s Services, Haringey Council