Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0033, written 10 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2021 |
|---|---|
| Reference | 2021-0033 |
| Deceased | Lily-Mai George |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Lily-Mai HURRELL SAINT GEORGE (died 02.02.18)
THIS REPORT IS BEING SENT TO:
1.
Director, Children’s Services
Haringey Council
Civic Centre
255 High Road
Wood Green
London N22 8LE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 19 April 2018, I commenced an investigation into the death of Lily-
Mai Hurrell Saint George, aged 10 weeks. Following a lengthy police
investigation, the coronial investigation concluded at the end of the
inquest on 8 February 2021. I made a determination at inquest that Lily-
Mai had been unlawfully killed.
4
CIRCUMSTANCES OF THE DEATH
Lilly-Mai was hurt by an adult with such force that she suffered 19 rib
fractures, other broken bones, and a severe head injury from which she
died. This took place on the afternoon/evening of Wednesday, 31
January 2018, while she was in the exclusive care of her parents.
1
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
Many healthcare and other professionals expressed the view that Lily-
Mai should not be discharged into the unsupervised care of her parents,
but Haringey Children’s Services nevertheless facilitated that discharge
from hospital on Thursday, 25 January 2018. Lily-Mai suffered her fatal
injuries six days later.
A legal gateway meeting took place on Wednesday, 31 January 2018
and the decision made that Lily-Mai should be placed in a residential unit,
with both her parents if they would consent. Lily-Mai presented to the
emergency services that evening, before such a placement was made.
If you have not done so already, I encourage you to listen to the recording
of the inquest so that you have a starting point for consideration of the
actions and omissions of Haringey Children’s Services.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 12 April 2021. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
, mother of Lily-Mai
, father of Lily-Mai
2
Haringey Safeguarding Children Board
Haringey Child Death Overview Panel
Barnet Hospital
Care Quality Commission for England
HHJ Thomas Teague QC, Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
10.02.21 ME Hassell
3
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