A health visitor raised concerns about a toddler’s safety but was IGNORED by her bosses – months before he was killed by his step-dad, a damning report has revealed.
Tragic 22-month-old Kieron Barley died after evil Craig Lewis violently shook him and then threw his lifeless body against his cot railings in June 2011.
Electrician Lewis, now aged 34, was jailed for eight years in April 2014 after admitting causing grievous bodily harm and manslaughter.
This week a serious case review found a health visitor had urged that Kieron be placed on a Child Protection Plan (CPP), but her request was rejected by two health managers.
The report found Keiron suffered development difficulties but enjoyed a loving upbringing for his first 20 months, when he and his mum Louise Barley had lived at a relative’s home.
But a violent incident at the home saw a health visitor recommend him for the CPP in March 2011.
Despite flagging up her concerns, the request was rejected by a manager at Birmingham City Council’s Children’s Social Care department and a reviewing team leader.
The report said: “The response of Children’s Social Care to the Health Visitor’s referral… can only be described as inadequate.
“In response to a safeguarding referral, in which the referrer indicates her belief that the threshold for making a Child Protection Plan is met, the Senior Practitioner makes two telephone calls (one back to the Health Visitor and one to Louise Barley) and then closes the case having decided that the only issue is one of housing and that can be dealt with by other agencies.”
It added that if Kieron had been subject of a Child Protection Plan (CPP) the role of Lewis would have come under “greater scrutiny”.
Three months later Lewis, who had a history of alcohol and drug abuse, flew into a rage because Kieron, who suffered from cerebral palsy, was late learning to walk.
He hurled the tot against the bars of his cot and he died three days later on June 22.
The report also heard three weeks before his death, doctors at Birmingham Children’s Hospital failed to detect Kieron had a broken back caused by Lewis who threw him to the ground.
Despite being taken to hospital on two more occasions, doctors failed to spot Kieron’s broken spine and internal injuries and discharged him with possible gastroenteritis.
On June 19, 2011, Lewis brutally attacked the tot again because he was angry about the messy state of their home in Denshaw Road, Kings Heath, Birmingham.
Lewis dialled 999 claiming the youngster collapsed and he was rushed to hospital with severe bleeding on the brain but died three days later.
A post-mortem examination said the youngster had suffered two serious injuries towards the end of his short life – a spinal fracture and a serious brain injury.
Barley 28, was jailed for 15 months for child cruelty, but had her sentence cut to six months by the Court of Appeal.
The report also criticised a doctor at Birmingham Children’s Hospital for failing to raise the alarm after discovering suspicious bruising on Kieron shortly before he died.
It concluded that Kieron’s death was “neither predictable, nor preventable” but that there was “undoubtedly considerable learning for all agencies”.
The report said: “The Senior Practitioner appeared to believe that if Louise Barley obtained her own accommodation then all risks/concerns will be reduced to manageable proportions, but this appears a massive leap of faith.”
The report said the assessment was “superficial at best and grossly optimistic in terms of Louise Barley’s capacity to safeguard Kieron, while the Team Manager’s authorisation of this piece of work is less than robust.”
The report said the junior member of the medical team “failed to follow appropriate safeguarding procedures.”
It added: “As a consequence there was no adequate scrutiny of the bruises (the explanation that it was caused by straps in a high chair lacked credibility) and an opportunity to intervene under safeguarding procedures was missed.”
The Birmingham Safeguarding Children Board has rejected many of the criticisms in the report.
In a statement, the organisation stated: “Regrettably the Board were unable to fully accept the report’s findings and recommendations.
“The Board takes the view the report is unfairly unbalanced in the emphasis it places on the role of Birmingham and Solihull Mental Health NHS Foundation Trust.
“It also does not meet the required standards in terms of accuracy, the presence of clear hindsight bias and objective analysis based on evidence.”
May 28, 2011: Lewis slams Kieron to the ground because he is not walking. Kieron goes to Birmingham Children’s Hospital where doctors fail to detect his broken back.
May 29, 2011: Kieron taken back into Birmingham Children’s Hospital after screaming and vomiting but is discharged.
May 30, 2011: Kieron taken back to Birmingham Children’s Hospital where doctors diagnose possible gastroenteritis.
June 19, 2011: Lewis again attacks Kieron and hurls him into his cot causing bleeding on the brain. Kieron rushed to Birmingham Children’s Hospital.
June 22, 2011: Kieron dies of massive injuries.
July 7, 2011: Lewis and Barley appear in court charged with causing or allowing Kieron’s death.
April 4, 2014: Lewis jailed for eight years after admitting manslaughter and causing death of a child. Barley jailed for 15 months after admitting child cruelty.