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Report says lessons must be learned after 'missed opportunities' to save 16-week-old Tequiilah

Victoria Burke and Paul Nicholson were jailed for causing the death of Tequiilah Burke in December 2013 Photo:

Newcastle City Council has admitted that there were 'missed opportunities' to identify and act on the risks faced by baby Tequiilah Burke, who died following a fight between her mother and boyfriend in December 2013.

The council made the comments after the publication today of a Serious Case Review into Tequiilah's death.

Its findings include:

  • There were four major incidents in the seven months leading up to Tequiilah's death, such as her mother being taken to hospital alleging she had been assulted, but "none led to multi-agency assessments and analysis", "all were missed opportunities to explore what was happening to the children"
  • "No proper assessment was done in relation to the risks" presented by Paul Nicholson, as Victoria Burke's new partner living in the house - despite the fact that he had given her address as his bail address, having been in court for robbery and burglary offences, and been apprehended for using legal highs
  • Allegations made by two other children in their care of physical harm inflicted by Victoria Burke were not fully investigated
  • There were procedural issues including some agencies not being present at meetings, strategic plans not being made, and records not being kept
  • Social services in Newcastle were "stretched" at the time, and Northumbria Police were not active participants in the child protection plans due to "operational capacity issues"

Victoria Burke and Paul Nicholson were both jailed for eight years each in December 2015 for causing the death of 16-week-old Tequiilah, who suffered fatal head injuries after being shaken.

Social workers had extensive involvement with Tequiilah and her family, but were still unable to save her. This is a "matter of huge regret to everyone involved in this case", Newcastle City Council said.

The report by Newcastle Safeguarding Children Board makes 11 recommendations for improvements in practice which could help reduce the risk of similar tragedies happening in the future.

In particular, the report notes the need for 'extra vigilance' in cases involving child neglect because warning signs may not be obvious.

Chair of the Newcastle Safeguarding Board, Colin Morris, said:

"In this case the review has identified some issues with the way procedures were applied and the way that agencies work together. It is important that lessons are learned from these recommendations and action is taken.”

However the report also noted that "even if practice had been better or different at certain times the outcome in this case may well have been the same."