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Child death review finds 'failures'
A serious case review has found failings by health professionals who missed opportunities to save a baby girl killed by her ex-soldier father who was wounded in Afghanistan.
The report said there had been a failure by agencies to "discover or take into account the troubled background" of Liam Culverhouse in the run-up to the death of his daughter Khloe Abrams.
There were also difficulties in information-sharing and communication, and an inability by medical services to identify and respond to Khloe's significant injuries.
Lance Corporal Culverhouse was last month jailed for six years after admitting killing his 19-month-old daughter.
He lost his right eye in a rogue attack at an Afghan National Police checkpoint in Nad-e-Ali, Helmand province, in November 2009.
Five of his comrades were killed in the attack.
Eighteen months after returning home, Culverhouse assaulted his then seven-week-old daughter Khloe at the family home in Northampton, leaving her fighting for her life in hospital for nearly 18 months.
Culverhouse, who was medically discharged from the Army, pleaded guilty to causing or allowing the death of the toddler.
Medical professionals found in 2010 that he had begun to have some Post Traumatic Stress (PTSD) symptoms and was feeling irritable.
A Serious Case Review (SCR) into Khloe's death by Northamptonshire Local Safeguarding Children Board found that there was a "failure to discover or take into account the troubled background of the father when providing universal services", as well as difficulties in inter-agency information-sharing and communication, and an "inability to identify and respond to the significant injuries suffered by the child".
The SCR found that nothing was ever discovered about the "maltreatment the child suffered during a short life" despite there being opportunities to do so.
In addition, had information about Culverhouse, who had a troubled and violent background that worsened following his injuries in Afghanistan, been properly shared it "should have led professionals to be very concerned about the safety of the child".
Khloe was admitted to hospital on May 8 2011 and found to have multiple injuries.
The SCR said that from the time of her injuries being sustained until her death on November 7 2012, she "remained a very sick child" and in particular, suffered from severe brain damage, epilepsy, pain, feeding difficulties, and constipation.
Due to the brain damage and associated retinal damage she could barely see and therefore her sensory awareness visually was very limited.
Khloe also required hand splints as due to the brain damage she had a level of spasticity in all limbs which led to her fingers rubbing into her palms.
The SCR said it was later found that Khloe's injuries were inflicted upon her deliberately and that they were sustained during four separate attacks.
She had been seriously injured by the time of a six weekly check-up which was carried out by a community nurse on behalf of a health visitor.
When the check was conducted, Khloe had several recent fractures to her ribs, arm, spine and leg, yet nothing untoward was noticed.
The SCR said: "The check was carried out in accordance with current service provision guidelines which may indicate that the current standard practice for conducting such checks is in need of review."
Culverhouse, who enlisted into the Army in January 2005 and joined the Grenadier Guards with whom he served for eight years, told doctors in August 2010, seven months before Khloe was born, that he had fears he may harm his other child.
His behaviour while in rehabilitation was described as "erratic and ill-disciplined" and it was found that he had issues with anger.
The SCR concluded that failings by two Army doctors to tell either Children's Social Care or the Army Welfare Service that he believed he was likely to harm his first child if left alone with him was a "serious error".
It added: "Measures may well have then been put in place which could have prevented (Khloe's) death."
A number of meetings were held with a unit welfare officer, the m ilitary doctor, his superior officers and occupational health therapist to address his continued lack of engagement and employment.
The unit were also aware that he was being seen by his military doctor and psychiatric nurse (CPN) to address the issues.
Culverhouse failed to attend his booked appointments with the Army Medical Services in January and February 2011, and was therefore discharged from the care of Departments of Community Mental Health Woolwich on February 8 2011.
The SCR said there was no follow-up mental health care offered nor were there any records to show that a referral was made back to his Regimental Medical Officer or to his unit regarding his failure to attend the appointments.
During Khloe's short life she was seen by a variety of health professionals who recorded that she had not put on a lot of weight since her birth, and at times appeared pale.
The SCR said that, in one such meeting with a GP in early May 2011, Khloe was awake and alert but there was a "strong likelihood" that she had suffered severe injuries by this time in her life.
The report said: "The Serious Case Review has revealed no evidence that any agency or individual discovered those injuries or expressed any specific concerns for (Khloe's) developmental milestones, health, well-being or upbringing.
"As a child she was 'visible' in the sense that she was seen appropriately by midwives, health visitors and her GP, as well as extended family.
"There had been no safeguarding or 'child in need' referrals from any third party to children's social care and she had never come to the notice of the police.
"No injuries to (Khloe) or physical signs of neglect which could reasonably have necessitated a safeguarding referral to Children's Social Care were noticed or recorded by any professional."
Other opportunities to learn more about Culverhouse were also missed.
"Family histories and parental backgrounds are crucial to assessments about parenting capacity," the SCR said.
A considerable amount of information was stored in health service files and databases about Culverhouse's early years and troubled childhood, some of which would have been highly relevant to those assessing his parenting ability.
Midwifery staff also failed to take active steps to ascertain the identity of Khloe's father and offer him support, the report added.
A number of recommendations were made and areas of good practice were also highlighted.
The SCR said the care provided by medical staff to Khloe from the time she was admitted to A&E in May 2011, until her death in Rainbows Hospice, was "first class".
It also said the police criminal investigation was "conducted in a highly professional manner".