A review into the death of Kemarni Watson Darby has found there were no missed opportunities to intervene and prevent his death.
On the June 5, 2018, Kemarni was found "lifeless" at his home on Beacon View Road in West Bromwich, West Midlands.
The three-year-old died after suffering abdominal injuries.
Following the three-year old's death in 2018, an independent review was commissioned by the then Sandwell Safeguarding Children Board.
Here are 10 things were learned from the review:
There were several risk factors that applied that indicated an Early Help Assessment should have been completed.
This included Watson missing routine medical appointments for Kemarni. The reason for missed appointments was not explored.
In summer 2017, Kemarni's progress was reported as ‘red’ meaning he had not reaching the expected developmental milestone according to their age. By autumn, Watson had failed to attend a number of appointments at Kemarni's nursery for lunch clubs, parents' evenings and workshops.
In March 2018, Kemarni was not at nursery because funding had not been made available or arranged by Watson. This may have been another sign that Watson was having difficulty coping.
The report found there was significant grounds for a health worker or teacher to have submitted an Early Help Note for intervention which they didn't do and would have provided additional support.
Given Watson's personal circumstances and the development issues faced by Kemarni, there should not have been a gap in the nursery education.
On the day Kemarni died his mother took him to the urgent care walk-in centre with a history of vomiting on and off for 5 days.
Following Kemarni's death, a lengthly police investigation began. The focus of the investigation was the timeline from which Kemarni was seen alive and well at the urgent care walk in centre and the discovery later that day that he was seriously injured. Was there any professional intervention at that time that could have prevented the catastrophic injuries to Kemarni?
The police investigation was complex and protracted. There were very few medical experts in the field who were able to provide the required evidence in a timely manner - one example was finding a consultant who could give an expert opinion on injuries that involve damage to a child's ribs. There was only one such person currently available nationally.
The review has also provided recommendations for partner organisations in the future.These included ensuring agencies are aware of the responsibilities to apply thresholds correctly and that the council need to include the voice of the child when recording information.
In a statement, Lesley Hagger, Chair of the Sandwell Children’s Safeguarding Partnership, said: “Our thoughts and sympathies are with all those who knew and loved Kemarni.
“Partners in Sandwell always look at what we can learn from sad cases like this and where we can identify areas for learning and improvement.
“The review did provide some learning from this case and I can confirm this has already been shared with professionals and implemented by agencies.
“This learning was around training for agencies regarding the thresholds for Early Help for families, promotion of funded nursery provision and childcare, and the need to better reflect the ‘voice of the child’ in records.
“As partners, we are fully committed to doing everything we can to protect children.
“Kemarni and family members did have contact with a number of services across the partnership. Kemarni himself had contact with ‘universal services’ – being those services we would expect any young child to have contact with.
“The independent review has concluded that there were no missed opportunities for professionals to intervene and prevent his death.
“There were no identified safeguarding concerns regarding Kemarni prior to his death in 2018, and there was no children’s social care involvement directly with him.
“Partners keep safeguarding training under constant review and there has been a process of continuous learning since 2018, including taking into account risks and challenges that emerged during the Covid-19 pandemic."