An investigation into the death of a seven-week-old baby in Northampton has concluded that no individual or agency could have predicted what happened to him.
Adam Kightley, aged 24, and Jacqueline Parker, aged 21, were both locked up for seven years in November after they were found guilty of causing or allowing the death of their baby son, Jamie.
Nottingham Crown Court heard baby Jamie died in Northampton General Hospital after emergency services were called out to the couple’s flat in Far Cotton, in Northampton, on March 17, 2012.
A post-mortem examination of Jamie revealed he had suffered a total of 46 fractures including broken legs and ribs and had suffered a fatal head injury “no longer than five hours” before his death.
A Serious Case Review published on Wednesday has revealed there were no serious failings by any individual or agency but a number of recommendations have been made.
The first recommendation is that Northampton General Hospital staff be informed that it is not against “data protection” laws to ask for information about the background of fathers.
The report states: “Little was known by professionals about the child’s father and it was revealed during the SCR that paternal medical records are not accessed by community midwives as it is considered that the community midwifes only have the professional/client relationship with the expectant mother and the unborn child.
“It is also perceived to be a breach of the Data Protection Act to access a father’s medical records. This latter point is wrong because there is a legitimate interest in a group of health professionals working with a particular family sharing information to better ensure that the potential vulnerability of a child is properly assessed.”
The report also states that it was a Student Health Visitor who carried out the home visits with the Kightley’s and “whilst there is no evidence that the work carried out was unsatisfactory” ** there were concerns about the process by which she was allocated this family and also a lack of adequate supervision.
The report states: “Had it been accessed, there was sufficient information available to suggest that this was not a suitable family for a Student Health Visitor to have been allocated.”
In the hours following the child’s death there was also a “significant breakdown” between the lead investigator from Northamptonshire Police and the paediatrician who saw Jamie.
The breakdown occurred between the police Lead Investigator and the Responsible Paediatrician and may have been partly caused by the fact that the first police officer did not arrive at A&E until an hour and a half after the child had been pronounced dead. This, in turn may have been partly due to a delay in informing the police that the child had collapsed at home and died.
The review also revealed an apparent failure to identify significant child abuse injuries by the Responsible Paediatrician involved in the case after the child had died, and therefore there appears to be a gap in the training of doctors within NGH.
In addition, there is a gap in service provision at NGH because it was not possible to carry out a full skeletal X-Ray on Jamie during the weekend he had been admitted to A&E.
The Serious Case Review also identified concerns relating to the ability of the police Lead Investigator to challenge the diagnosis by the Responsible Paediatrician, and also concerns that despite a considerable body of other evidence, the police felt that only a clear conclusion by the Consultant Paediatrician could give them ‘reasonable suspicion’ that a crime had been committed.
The report states: “It is evident that Northamptonshire Police does not comply with guidance issued by the Association of Chief Police Officers to the effect that a Detective Inspector should be deployed as the Lead Investigator in cases of unexpected childhood death.
“Had such an officer been so deployed it is possible that a better evidential assessment would have been made and in particular that a Forensic Pathologist would have been asked to review photographs thre days before this actually took place.”
**NOTE In an earlier version of this story we mistakenly quoted the Serious Case Review with regard to a student health visitor it mentions. The report actually says “there is no evidence that the work carried out was UNSATISFACTORY”. We mistakenly wrote “satisfactory”.
Furthermore, the report said all health visitors carried out their duties properly with regard to Jamie Kightley. It also found nothing they could have done would have prevented his death.
We apologise for any distress caused by our error.