A report has found serious failings by health professionals who missed opportunities to save a baby girl killed by her father - a former soldier from Northampton.
Lance Corporal Liam Culverhouse was jailed for six years after he admitted causing the death of his daughter Khloe Abrams.
The Grenadier Guardsman was medically discharged from the Army after losing his right eye in an attack that killed five of his comrades.
Culverhouse was described in today's report as a "violent and troubled" man whose troubles worsened after receiving his injuries in Afghanistan.
After he returned home, Culverhouse attacked his daughter when she was 7-weeks-old.
A Serious Case Review into her death has today found a breakdown in communication between health professionals may have prevented the girl from being saved.
The report states that several months before Khloe was born, Culverhouse had told two Army doctors that "he was likely to harm his child if they were left alone together".
However, the report says neither doctor shared that information with civilian safeguarding agencies.
The report says this failure "denied those agencies the opportunity to fulfil their responsibilities to safeguard and promote the child's welfare."
The report goes on to say that further opportunities were missed to find out about the father's "troubled early years" which would have triggered action to protect the child.
Other failures found by the report included:
- Midwifery staff failed to take the proper steps to find out who the father was and to offer him support, despite him being at the birth.
- During a routine visit to the GP nothing untoward was noticed. However it is now known the child had several fractures to her ribs, arm, spine and leg.
- A number of concerns were found at the week 6 check such as the mother feeling low, the father having serious injuries and the babies weight had dropped. However no steps were taken by the healthcare team to meet with the father.
The report described as "first class" the care provided by medical staff once the child had been taken to A&E in May 2011 until her death 17 months later.
Timeline of events:
- May 2011 - Khloe's parents call the family GP and report the baby as "un-rousable" and "very cold to touch".
- 15 minutes later - Khloe is taken to Northampton General Hospital by her parents. The child was found to be in respiratory arrest and was revived.
- Full examination finds the child had multiple injuries that were thought to be non-accidental.
- November 2012. Khloe dies. She was suffering from brain damage, epilepsy and other conditions.
- November 8, 2013 - Liam Culverhouse admits in court causing the death of his daughter.
- January 17, 2014 - Liam Culverhouse sentenced to six years in jail.
Major General Ewan Carmichael, Director General Army Medical Services, said:
“This was a tragic case and our thoughts are with the family at this difficult time.
“We take the safeguarding of children seriously and despite having procedures in place, we could have done more to help protect the soldier’s family.
"We have since taken a number of steps to improve information sharing between Army units, the Army Welfare Service, Defence Medical Services and with their equivalent civilian organisations.
"We will now consider all of the recommendations of the Serious Case Review to ensure our procedures are as robust as possible.”
Northampton General Hospital Director of Nursing and Midwifery, 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”.
Read the full Serious Case Review of the circumstances concerning Leah Barnes here: http://www.lscbnorthamptonshire.org.uk/usercontrolledlcmsareascr/uploaded_files/Leah%20Barnes%20SCR%20-%20Overview%20Report%20-%20No%20password.pdf