The safety of two young children murdered by father figures was “seriously undermined” after the significance of the killers’ criminal past and history of domestic abuse was overlooked by agencies, a serious case review has concluded.
The Northamptonshire Safeguarding Children Board (NSCB) said there were “lost opportunities” leading up to the deaths of two-year-old Dylan Tiffin-Brown in Northampton and one-year-old Evelyn-Rose Muggleton in Kettering in December 2017 and April last year.
Dylan’s father Raphael Kennedy, 31, and Evelyn-Rose’s mother’s boyfriend Ryan Coleman, 23, were both jailed for life for the youngsters’ murders.
In Dylan’s case, the NCSB concluded that agencies “failed to fully appreciate the significance of (Kennedy’s) chronic history of domestic abuse and extensive history with the police for drug-related offences”.
The report suggested other factors such as a significant level of sick leave and high turnover of staff also contributed to the missed opportunities.
Keith Makin, chairman of the NSCB, said: “At the heart of this is a young boy, just two years old, who died at the hands of a violent father.
“Perhaps chief among the learning from this tragic case is how agencies need to improve information-sharing within their own organisations as well as between partners.
“The report recommends a further review of training to ensure ‘think child’ is front and centre when it comes to the way safeguarding professionals approach every case.
“There can’t be a clearer message than that.”
Addressing the death of Evelyn-Rose, the NSCB said two social workers had been allocated to the case which had started to “drift, with little if any attention being paid to the children’s welfare”.
The review said there were missed opportunities with police involvement, including Coleman being bailed to a non-specific address after initial questioning and returning to Evelyn’s mother’s home – which was in breach of his community order.
Despite not complying with the community order, a risk assessment was not followed up after further offending and despite Coleman’s “significant” criminal history.
Mr Makin said: “This is another extremely distressing case in which a young life has been taken.
“This was a very challenging review, but it has identified several areas of weakness among the agencies involved.
“Agencies collectively failed to share information that may have built up an overall picture of low-level neglect that would have ensured more effective intervention than what actually happened.”
The serious case review recommended an improvement in information-sharing between agencies after the missed opportunities in the two cases.
The NSCB also said police forces warning about risks posed by an adult’s behaviour towards a child “should be taken more seriously”.