The Health and Social Services Department of Hackney Council have been condemned by a coroner for “serious and cumulative” failures in a case which led to the deaths of two children in January 2007.
The children were the subject of a child protection case and were being raised by their father although they had regular but supervised contact with their mother. However, citing a lack of communication and organisation as well as a catalogue of failures on the part of several individuals in mental health and social services, the coroner reported that the mother was allowed three unsupervised overnight visits. On the third visit, the mother, suffering from paranoid schizophrenia, killed both children in the belief that her own children had been stillborn and replaced.
The coroner added “If the risks to the children had been properly recognised and managed, it is probable that the mother would not have had unsupervised overnight contact with the children on the night of 26 January 2007”.
In a Serious Case Review, one failing which was noted was a decision to close the case on the basis that there were no immediate child protection concerns.
The coroner also noted that social service within Hackney Council had been transformed since 2007.