Kyrell Matthews died in October 2019 after suffering injuries including 41 rib fractures and internal bleeding.
Last week, his mother, Phylesia Shirley, 24, was found guilty of manslaughter.
Her former partner Kemar Brown, 28, was convicted of murder.
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Local Spotlight - Croydon Council
A review into Kyrell’s death, by the Croydon Safeguarding Children Partnership, finds that his mother was known to both social services and health visitors due to her own adverse childhood experiences. She had also expressed mixed feelings about her pregnancy and had episodes of depression, according to the report.
“She was offered a range of services because of her vulnerability but did not engage well,” the report states.
Following Kyrell’s birth she began to engage with health visitors, however, this support lapsed when the pair were moved to different accommodation.
Further chances were missed to protect Kyrell when a child and family assessment, undertaken after reports of domestic abuse at the family home in Thornton Heath, Croydon, found that a child in need service was not required.
The report criticises the council’s failure to signpost the family back to early help services following the assessment.
In May 2019, Kyrell was taken to hospital suffering a head injury which his mother said he had sustained after jumping off a sofa.
Despite concerns by hospital staff about how Kyrell sustained the injury, it was deemed accidental.
The council agreed to arrange a home visit to Kyrell after he was discharged but this was cancelled because “the threshold for a referral had not been met”. Children’s services failed to notify the hospital about the cancellation.
Social workers dismissed the hospital safeguarding team’s concerns as “professional anxiety”, the report states, noting that at that time, Croydon’s children’s services was recovering from an “inadequate” Ofsted rating.
At the time Croydon’s safeguarding team was “more crisis-led and thus seeking to accept only the highest priority referrals”, the report adds.
“To close the case without informing the hospital was a mistake as this would have led to further dialogue about the hospital’s concerns,” it states.
Police also failed to inform social workers after visiting Shirley’s home to follow-up on concerns raised by neighbours about domestic abuse involving Brown.
This failure meant that the council was unaware he had convictions dating back to 2006 for offences of robbery, assault, burglary, affray, possessing weapons, possessing cannabis, breaching bail conditions and domestic abuse.
He had been assessed by the Probation Service as a high risk of harm to the public, to rival gang members and to previous or future partners, the report states.
Shirley’s failure to take Kyrell to nursery and GP appointments, including to receive vaccinations, meant that further opportunities were missed to identify any risk posed to the child, according to the report.
Debbie Jones, chair of Croydon Safeguarding Children Partnership, said Kyrell’s death highlights “the extreme vulnerability of very young children, who are able to be kept hidden from view”.
“Kyrell’s mother received good support during his early infancy, but when he grew older, he did not attend nursery or pre-school, and was often not brought for routine GP appointments. For many months, Kyrell did not come into contact with professionals who might have noted concerns.
“However, there were some opportunities to identify risks to Kyrell, and to be more assertive in engaging and challenging those who were entrusted with his care. We very much regret that these were not taken, and we have made changes to the way we work as a partnership to ensure that together, we do everything in our power we can to protect children like Kyrell,” she added.
Shirley and Brown are due to be sentenced on 25 March.
