The risks posed to a newborn baby by the abusive stepfather who went on to kill him were not taken seriously enough by authorities, an investigation has found.
Teddie Mitchell died at just 12 weeks old after suffering a catalogue of injuries to his head, spine and eye, and a bleed on the brain inflicted by his mother's partner Kane Mitchell hitting him off a hard object.
The baby died in November 2019, and both his mother Lucci Smith and Mitchell have been convicted for their crimes, which featured on two episodes of the Channel 4 series 24 Hours in Police Custody earlier this year.
Mitchell, of St Neots in Cambridgeshire, was jailed for at least 18 years after being convicted of murder while Smith was handed a two-year community order for neglect in January 2021.
An independent safeguarding review into the death was commissioned by the Cambridgeshire and Peterborough Safeguarding Adults and Children Partnership Board, and made a series of recommendations.
It highlighted communications failures between the agencies involved with the family, and insufficient action taken after reports of domestic abuse within the family.
On one night, four incidents of domestic violence were reported in a single night, and neighbours reported that the "atmosphere" in the house had changed since Mitchell's arrival in the house.
"The review finds that the initial responses to concerns of domestic abuse and the welfare of the children (ie the offer of early help) were not sufficiently robust," said Catherine Powell, the author of the report.
'Controlling, coercive and violent'
It found Mitchell, who was presented to authorities as Teddie's father, had a "significant history of a pattern of abusive behaviour towards intimate partners and ex-partners and criminal convictions resulting from his controlling, coercive and violent behaviour".
Several agencies had information about the extent of his abusive history, "not all of which was shared in a timely way" the report found, adding that "some inaccuracies in recording were made" that changed the perceived level of risk in the family.
The report said: "In short, the arrival of this partner, and his status and presence in the household, changed the dynamics, put the children and their mother at risk of significant harm, and ended with the tragic death of [Teddie]."
Teddie died in hospital on 11 November 2019, 10 days after being assaulted in his home in St Neots by Mitchell.
During Mitchell's trial, the judge said the assault involved the "violent striking by Mr Mitchell of Teddie's head against a hard or unyielding surface". This fractured the boy's skull and caused brain, spinal and eye injuries, he said.
On another occasion, Mitchell had fractured two of Teddie's ribs and his collar bone.
He found that Mitchell did not intend to kill the child but that "in sudden temper and frustration with Teddie" he intended to "cause really serious harm" to him.
The report also found that many professionals thought Mitchell was Teddie's biological father - a factor that may have led them to underestimate the risks he posed.
"Research on child homicide references the 'clear danger' that may be presented by a non-biological carer," it said.
Teddie's biological father, the report said, hopes "that the learning from this review will help to prevent further infant deaths in the future".
Baby was attacked as mum did school run
During the trial, Cambridge Crown Court was told Mitchell and Smith had been in a relationship for about eight months and had lived together with baby Teddie.
At 3pm on 1 November, 2019, the ambulance service was called to Pattison Court, St Neots, where Teddie was found to be unresponsive and in cardiac arrest.
Smith had left Teddie in the care of Mitchell while she did the morning school run. When she returned, she noticed he seemed lethargic and wouldn’t take his bottle.
She later contacted a GP after Teddie’s condition deteriorated. They advised her to call 999 but she waited about half an hour before calling them.
Teddie was rushed to the special care baby unit at Hinchingbrooke Hospital in Huntingdon, where doctors discovered he had a fractured skull and a significant bleed on the brain.
Officers and medical staff were concerned about how Teddie received his injuries and Mitchell and Smith were both arrested at the hospital. Teddie was later transferred to Addenbrooke’s Hospital in Cambridge for a specialist neurology assessment and placed in intensive care on life support, where doctors concluded he would not recover.
Medical staff kept Teddie stable on a life support machine, however, after 11 days, a decision was made to withdraw the life support and Teddie passed away shortly after. A post mortem revealed he died as a result of his fractured skull and lack of oxygen to the brain.