Warning: This article contains an image of child abuse that readers may find distressing
Six-year-old Arthur Labinjo-Hughes was murdered by his stepmother Emma Tustin at their home in Solihull in June 2020.
He had been seen by social workers just two months before his death - but they concluded there were no safeguarding concerns.
Tustin was jailed for a minimum of 29 years for his murder, while Arthur's father, Thomas Hughes, was sentenced to 21 years for manslaughter.
Star was 16 months old when she was murdered by her mother's partner, Savannah Brockhill, at their home in Keighley, on 22 September 2020.
She suffered a fatal cardiac arrest after months of "neglect, cruelty and injury" at the hands of Brockhill and Star's mother, Frankie Smith.
The report reveals that what happened to Arthur and Star are not isolated incidents and their deaths reflect wider problems in child safeguarding practice, including poor information sharing between professionals and weak decision-making.
June 2018 - First children in need assessment
A domestic abuse incident between Arthur's mother and new partner (when Arthur was not present) prompted a Children in Need assessment by Birmingham Children’s Trust (BCT) that concluded with no further action.
February 2019 - Arthur's mum arrested
Olivia Labinjo-Halcrow was arrested for domestic murder of Gary Cunningham. Arthur moves in full time with his dad.
A further Children in Need assessment by Birmingham Children’s Trust (BCT) concluded with no further action. Arthur’s father was assessed to be a "protective factor" for him.
October 2019 - Arthur had no contact with his maternal family
Arthur's father stopped the contact between Arthur and his mother, his maternal grandmother and the maternal extended family.
Around the same time, in autumn 2019, Arthur's dad Hughes had begun a relationship with Tustin.
December 2019 - Mum attempts to reconnect with son
Arthur's mother initiated the process to establish contact arrangements with Arthur againthrough a Child Arrangement Order.
Children and Family Court Advisory and Support Service (CAFCASS) became involved with Arthur as part of this process.
January 2020 - Arthur referred to mental health services
Escalating concerns about Arthur’s behaviour and emotional well-being in the autumn of 2019 were noted by staff in school - and by his father at home.
These concerns led to a referral to SOLAR (Child and Adolescent Mental Health Service) from his GP.
Arthur was assessed by SOLAR for specialist support but was not offered a service.
On the same day, Arthur was seen by a CAFCASS officer in the course of the completion of a Section 7 report for the Family Court.
CAFCASS represents children in family court cases in England. They independently advise the family courts about what is safe for children and in their best interest.
A Section 7 report is often requested in child arrangements cases - and it is a way for a judge to obtain assistance from an expert in the field of child welfare when deciding an issue regarding the child's upbringing
Lockdown is established in the UK and Arthur moves with his dad Hughes from his paternal grandparent’s home into the home of Tustin's.
April 16, 2020 - Grandparents raise concerns about bruising
After a fallout in March 2020, Tustin and Hughes reconcile their differences. Arthur's dad returns to Tustin's home with his son.
Paternal grandparents voice growing concerns about bruising with Solihull Emergency DutyTeam (EDT).
EDT call police that evening relaying grandparents concerns. Police deny request for a ‘Safe and Well’ visit based on their observation of Arthur the previous day.
April 17, 2020 - Social work team check on Arthur
Following paternal grandparent’s concern, the MASH send social workers to check on Arthur.
Social workers report that Tustin's son - who has not been named - and Arthur are willing to show bruises – no safeguarding concerns were identified. An offer of ‘Life Story’ work is made.
April 18, 2020 - Police receive photos of bruising
Photographs of bruising are sent to the police by Arthur's uncle. Police receive the pictures but never sent onto the MASH.
April 24, 2020 - MASH receive photos of bruising
Family members continue to express their concerns to Children’s Social Care, the police, and Arthur’s school.
The photos of bruising are passed onto the MASH by maternal grandmother on April 24.
End of April - No further investigation
It was decided that no further investigation was needed in relation to the family’s concerns about bruising.
It was hoped that the family would consent to an offer of "life story" work with Arthur, which would be an opportunity to monitor and escalate any safeguarding concerns.
At the end of April, Arthur's father declined the offer of "life story" work.
June 16, 2020 - Emergency services called
Emergency Services called as Arthur is suffering cardiac arrest after sustaining a severe head injury. He dies the next day.