Inquiry finds that Declan Hainey death was avoidable
A fatal accident inquiry has found the death of toddler Declan Hainey may have been avoided if care agencies properly supervised his drug addict mother.
The child's mummified body was found in his cot in March 2010 - eight months after he was last seen alive.
Kimberley Hainey was jailed in 2012 for her son's murder but her conviction was later quashed on appeal.
The inquiry found parental neglect was a factor in his death along with failures among social care teams.
The fatal accident inquiry was conducted by Sheriff Ruth Anderson at Paisley Sheriff Court.
Sheriff Anderson found: "Having determined that on the balance of probabilities neglect was a contributory factor, the following defects in the system contributed to Declan's death.
"There was no system in place whereby one of the agencies responsible for Declan's well-being was in overall charge and there was no system whereby one named individual was responsible for coordinating all available information.
"This defect resulted in no formal inter-agency meetings taken place, especially in the period from February 2009."
Sheriff Anderson continued: "Had such systems existed then those responsible for the care of Declan would have been aware of all that was happening and all that was not happening and steps would have been taken to protect him from the risks resulting from Kimberley Hainey's inability to take proper care of her son.
"There was no system in place in relation to obtaining medical information. There was a fundamental lack of knowledge by social work staff at the Royal Alexandria Hospital as to what information they were entitled and how they might obtain it.
"As has been determined, had such information been available, there would have been a material difference in approach to the case by both Family Matters and Health Visitors and decisions taken in the initial assessment process would have resulted in more protection for Declan."
Sheriff Anderson rejected submissions on behalf of Renfrewshire Council that its staff had made "reasonable professional judgments" before Declan was born.
She said it was known that Hainey had failed to prepare for Declan's birth, had a "chaotic drug history" and was drinking heavily "while on a methadone programme".
The sheriff said: "Had reasonable professional judgment been exercised, then child protection measures would have been taken."
She added: "The risks to Declan were never analysed properly."
Sheriff Anderson noted that "important decisions were taken when no records were available, and no notes or minutes kept".
She said that "when decision were taken, it was often not easy to understand the basis of which they were taken".
The sheriff said: "Gillian Turner claimed on the third day of her evidence, having been questioned on the issue of note-taking that she had kept notes of this case and others in a personal notebook, which she later shredded after she left Family Matters.
"If that was truthful evidence, it seems an extraordinary and unprofessional action for a senior social worker to take.
"Notes about cases should be kept in files, not in a personal notebook which is taken from the agency and later destroyed."
Sheriff Anderson said "there were failures on the part of professionals to communicate instructions in a clear and unequivocal way".
It was noted that unsuccessful supervision visits were not properly communicated between social care workers.
The inquiry identified "defects in the system" such as a lack of clarity over whether there was a "lead individual" in handling cases at the same time as "the lead agency".
The sheriff also said it was clear that defects also existed in procedures at the time for "obtaining all necessary medical information" which would have informed decision making.
Sheriff Anderson also highlighted issues with inadequate staffing around the care teams who were in charge of protecting Declan.
Andrew Lowe, Independent Chair of Renfrewshire Child Protection Committee, said care services in the area fully accepted the inquiry findings.
He said: "Declan's death was a tragedy. The loss of this young boy demands that all of us examine the findings from this inquiry very carefully and apply the recommendations it contains.
"Much has been done in the five years since Declan's death to strengthen child protection services in Renfrewshire.
"All of us involved in this work recognise the importance of a prompt and thorough response to the Sheriff's findings."
Mark Macmillan, leader of Renfrewshire Council, said: "We must never forget that Declan's death was a tragedy where a young child needlessly lost his life.
"Children need a home where they are loved and looked after. Providing that safe, nurturing environment has always been and always will be our over-riding goal. There is no higher priority for this council and our partner agencies.
"In recent years, the organisations involved locally have put in place a series of improvements in the way we work together, monitor and act in such cases. We now have new evidence and new recommendations which will support that crucial work.
"Sheriff Anderson has acknowledged the progress we have made in strengthening child protection services."
Annette Bruton, chief executive of the Care Inspectorate said that "Declan's death was shocking and extremely distressing, and provoked deep sadness across Scotland".
She said the Care Inspectorate would now conduct a full joint inspection of services for children and young people across Renfrewshire with Healthcare Improvement Scotland and Education Scotland.
She added: "During these joint inspections, we routinely look at a number of the recommendations made by the Sheriff in this tragic case, particularly how children are supported by social workers, how vulnerable children get the help they need, how agencies work together and how staff are trained.
"We expect children who are at risk to have regular and appropriate contact with social workers, health visitors and professionals, and support the Sheriff's call for notifications of concerns to be addressed robustly by those responsible for protecting children."