There were missed opportunities to protect a Welsh toddler who was murdered by her stepfather four years ago, a review has found.
Lola James, who died in July 2020, was fatally attacked in her home in Haverfordwest, Pembrokeshire, by her mum’s boyfriend, who claimed she had fallen down the stairs.
A report into the two-year-old’s death published on Thursday has identified a range of issues at various organisations, including proper processes not being followed.
Kyle Bevan, 32, of Haverfordwest, Pembrokeshire was given a life sentence for murdering Lola in July last year.
Her mother, Sinead James, 31, also of Haverfordwest, was also found guilty of causing or allowing the youngster’s death and given a six-year jail term.
The judge concluded Lola’s mother was asleep when the little girl suffered the injuries that caused her death but that she was aware that Bevan had been abusing Lola, “yet did nothing” to protect her.
The child practice review by the Mid and West Wales Safeguarding Children Board set out a series of failings, with reports closed without any real detail, overworked staff and visits not made when they should have been.
Speaking to the PA news agency, Emma Sutton KC, who led the review, said: “There was a real issue on the ground in relation to the health visitor service, that although they were wanting to do their very best in obviously difficult situations, there was a prolonged period of time where a health visitor didn’t see Lola.
“So although there were conversations with Lola’s mother, there wasn’t an ability to see how she was.
“Had the health visitor been able to go into the property before July 2020 (they would have seen) the inappropriate home conditions, which in itself would have caused alarm bells in terms of child protection concerns and also bruising on Lola, that came out in the criminal trial.”
While Lola’s death occurred during the Covid pandemic, Ms Sutton said there was no direct evidence that it negatively impacted the care that Lola received, with various services still able to access the home.
The report said that Lola suffered a violent attack by Bevan on the evening of July 16 2020 and into the morning.
Ambulance staff raised concerns that the injuries were inconsistent with falling down the stairs, as the mother had claimed on the phone to 999.
Lola was taken to the local hospital and later pronounced brain dead.
Bevan was known to the police since at least March 2019 for domestic incidents related to his own mother, who told the court he had an “anger problem”.
The review said concerns had been raised in January 2020 by a health visitor to Lola’s home, who said the mother was finding her daughter demanding, and at previous visits, she was unwashed, with her feet black with dirt.
While the health visitor submitted a multiagency referral form – to bring in social services – the review said there were a number of “missed opportunities” to arrange additional home visits, which could have allowed Lola’s well-being to be ascertained.
Those visits could also have uncovered that Bevan was living at the address, which James had not revealed to the team, and the condition of the home, which “would (on its own) have raised child protection concerns”.
Children’s Services opened a report on Lola which the review criticised as “lacking in detail and analysis”.
The board said a report had been dated February 2020, but it became apparent that the assessment had not been completed by the named social worker and had instead been created and closed by a team manager in March of that year.
The social worker named had been on sick leave, with the team “struggling under the pressure of the relentless workload”.
She told the review board that she had not anticipated that her assessment would be closed by her supervisor while she was off, as it was not usual practice.
The review found the closure of Lola’s case was “not appropriate”.
It said: “This is not a practice that was endorsed by children’s services at the time, or to date.
“The consequence of what happened in this case is that an assessment of (Lola’s) needs was not properly undertaken by children’s services, as required.”
Ms Sutton said the local authority now needs to look into why Lola’s case was closed in such an “unorthodox way” and whether any other children’s cases under similar circumstances.
Her report also found that Lola’s father had not been contacted by social workers, nor had he been informed by police about incidents at the home.
Had he known, he suggested she could have been moved into his “bubble” during the pandemic.
The report admits Lola’s death may not have been prevented if the case had not been closed by social services or more health visits had been carried out, but more should have been done.
The report listed seven learning points and 11 action points for improvements to be made to prevent future deaths.
Actions recommended include ensuring adequate staffing levels and that information be better shared between agencies.
Pembrokeshire County Councillor Tessa Hodgson, cabinet member for social care and safeguarding, said: “Pembrokeshire County Council would first like to convey their sincerest condolences to the family of Lola James and to all those who have been affected by her murder, over four years ago.”
She described the review as a chance for the authority to reflect on its practices and to learn from the observations in the report.
She insisted that an action plan to deal with the issues was already being implemented with a social care improvement board being established.
She said: “We hope also that the report, will contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities in the West Wales region and beyond.
“It is imperative that we take all opportunities to improve our services, and ensure that children and families receive the best quality of support available.”
A joint statement on behalf of Pembrokeshire County Council, Hywel Dda University Health Board and Dyfed Powys Police said: “All agencies involved in this report wish to convey their sincerest condolences to the child’s family and to all those who have been affected by the murder of a child in such appalling circumstances.
“This review has been an opportunity to reflect and share learning amongst all partner organisations and practitioners on a multi-agency basis, and we acknowledge the commitment and contribution of those who have taken part in the review process.
“All agencies take very seriously the opportunities that this review presents, to consider our practice and improve how we protect vulnerable children.
“We hope that the report will also contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities.’
