The serious case review into Khloe Abrams’ death says that her dad, Liam Culverhouse, was a “violent and troubled man” and there were many signs his troubles worsened due to the injures he received while serving in the army.
It said no professional or any extended family member raised any child protection concerns for Khloe before her admission to hospital in May 2011.
It said there were other opportunities missed to learn more about the father and that “a considerable amount of information” was stored in health service files and databases about Liam Culverhouse’s “troubled early years”.
The report added: “Some of this would have been highly relevant to those assessing this parenting ability.
“Midwifery staff did not sufficiently ‘Think Family’ when they were providing a service to the child and her mother, and this was contrary to the national guidance provided by the Nursing and Midwifery Council.”
Northampton General Hospital director of nursing and midwifery, Ms Suzie Loader said: “The Trust fully accepts the recommendations made by the independent author as part of the Serious Case Review and recognises the need to work swiftly to ensure that similar situations cannot recur. To this end, we are looking closely at the processes and procedures we have in place to ensure that they are fit for purpose and have beneficial effect for children and young people”.
The report also added that Khloe’s injuries, which led to her death in Rainbow Children’s Hospice a year later, would have been sustained by the time of her six-week visit.
It says: “The child had been seriously injured by the time of a routine six-weekly checkup, which was carried out by universal healthcare staff and a non- routine visit to the GP the following day.
“When the checks were conduced it is not known that the child had several fractures to ribs, arm, spine and leg, yet nothing untoward was noticed.”
Kevin Crompton, Independent chair of Northamptonshire’s Local Children Safeguarding Board said that the individual health staff were not at fault as the injuries may not have been visible.
He said the thoroughness of the all such checks needs to be reviewed.