Oxfordshire toddler's death review reveals 'missed chance'
A 22-month-old boy's death may have been prevented if organisations had worked more effectively together, a report concluded.
Child Y, from Oxfordshire, died from a fractured skull in November 2010. His father was jailed for 15 months in May, after admitting child neglect.
Oxfordshire Safeguarding Children Board's serious case review found a concern raised over his condition five months earlier was not acted upon.
The NSPCC called it "an awful tragedy".
Oxfordshire County Council expressed its sorrow, calling it "a tragic set of circumstances".
The report showed eight different agencies, including the county council, the former Oxfordshire Primary Care Trust and Thames Valley Police, had an involvement with Child Y and his family.
It concluded there was a "missed opportunity" to address the child's circumstances.
The serious case review found an anonymous tip-off was received in June 2010 by social services over the boy's condition.
It said he displayed signs of developmental delay and possible bruising from falling over.
But, the report found, it was not fully recorded or investigated and only came to light following his death.
In September 2009, a visit to a GP for a routine vaccination saw a nurse examine a number of injuries and bruises.
A visit to a hospital later the same day, following visits from police and social services, resulted in a paediatrician accepting the parents' explanation the injuries were sustained accidentally.
Child Y's mother suffered from mental health issues and was being harassed by a former partner, as well as being in debt.
Furthermore, on New Year's Day 2008, police were called to her house after she had taken an overdose and cut her wrists, for which she later received hospital treatment.
She gave birth to Child Y in early 2009, at a time when she continued to face housing and financial problems.
In November 2010, Child Y's parents took him to their local hospital. He was found to have extensive serious head injuries, including a fractured skull, as well as bruising to his abdomen and skull.
He died a week later. His mother has since moved to Ireland.
'Capacity to parent'
David Tucker, head of policy at the NSPCC, admitted it was distressing to hear better co-ordination could have saved the infant's life.
He said: "There is evidence that multi-agency structures are being developed across the country to allow better sharing of information.
"It's really important information is joined-up to ensure a holistic view of a mother's capacity to parent a child."
In a statement, Oxfordshire County Council said: "Organisations involved have rightly been called upon to explain their role.
"The council makes it the highest priority to act swiftly on recommendations made in a serious case review, as we have done in this case."
Thames Valley Police, Cherwell District Council and Oxford University Hospitals NHS Trust said they all acknowledged the review's recommendations, extending their sympathies to the child's family.
Child Y's father later had his sentence reduced to 10 months after an appeal.
- This article was amended on 16 December to reflect the reduction in Child Y's father's prison sentence.