Teddie Mitchell: Report says warning signs were missed

The independent report, carried out by safeguarding consultant Catherine Powell, on behalf of the Cambridgeshire and Peterborough Safeguarding Adults and Children Partnership Board, makes harrowing reading.

It details several occasions when concerns of domestic abuse and the welfare of the children were not followed up fully. Neighbours reported noise and arguments after Kane Mitchell, who was not the baby's biological father, moved into the family home - and this moment in time was described as "key".

Schools were aware that Mitchell had previously been a perpetrator of serious domestic violence, as he had had an earlier relationship with another parent of children at the school. In the weeks before Teddie's death, the children were now often late for school and sometimes dirty and wore the same clothes for several days. The report says before Mitchell’s arrival there were no issues.

Ms Powell looked at the work of several agencies, including Cambridgeshire Police and the North West Anglia NHS Foundation Trust; which runs Hinchingbrooke Hospital and the Cambridgeshire and Peterborough Independent Domestic Violence Advisory Service and makes seven recommendations.

One of the recommendations highlights a tendency by professionals to process child welfare concerns based on the "hierarchy of referrer" that essentially means that concerns from neighbours or family members are given less weight than professionals.

During his short life, baby Teddie, who is referred to as "Stephen" throughout the report, suffered a catalogue of injuries, including a broken spine, several rib fractures and two broken clavicles, and then finally, a blow to his head that was described by a coroner as a "catastrophic and unsurvivable" injury. Some of the injuries were described as "healing injuries" which is indicative of "physical abuse over time".

Teddie was taken to the A&E Department at Hinchingbrooke Hospital on November 1, 2019 after a 999-call was made from the family's flat at Love's Farm, in St Neots. He died 10 days later. His injuries were likely to have been the result of being gripped hard, shaken vigorously and having his head struck against a hard surface.

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Kane Mitchell, 31, was later found guilty of murder and received a life sentence with a minimum tariff of 18 years. Teddie's mother, Lucci Smith, 29, was found guilty of child neglect and handed a two-year community order.

At the time of Teddie's emergency admission to hospital, children’s social care services were completing a child and family assessment. The decision to undertake the assessment followed police call outs and referrals from neighbours and others concerned about constant arguing and screaming and the children crying. The concerns, which arose over a period of several months, dated from the time Mitchell moved in.

The report refers to "four practice episodes" to assist health and social care professionals and highlights "systemic issues" which could have picked up Teddie's "faltering growth".

Teddie was seen by a GP at the age of nine weeks, for the ‘six-to eight-week’ developmental check and he was not weighed or measured. The stated reason for this was that his weight and his head circumference "had been done by the health visitor two weeks previously".

Crucially at this point, Teddie's and his half-siblings had been discussed at in-house practice safeguarding meetings on four occasions and an alert was added to the records. The practice was aware that a social worker was undertaking a child and family assessment.

The report states: "No concerns about 'Stephen's' growth or development were identified by the GP or raised as a concern by his mother. This appointment was the last time 'Stephen' was seen by a health professional prior to his emergency admission to hospital 10 days later. 'Stephen’s' pattern of faltering growth was not identified at this appointment, or in the earlier contacts with health professionals. This is important because, in the absence of an organic cause, his slowness in gaining weight/weight loss may have reflected the presence of physical injuries or neglect."

Teddie had already suffered non-accidental bone fractures at the time of his routine health appointments, identification of these covert injuries would have required specialist x-rays (a skeletal survey) undertaken as part of a child protection medical, according to the review.

"The emergent pattern of faltering growth raises the question of whether there was a window of opportunity for a referral to a paediatrician in the context of known safeguarding concerns, including domestic violence and abuse."

The recommendations include the way in which agencies record and update the details of family/household members and recording current addresses. This includes any changes in an intimate partner during pregnancy.

It was also recommended that concerns and referrals about child welfare are not processed based on a hierarchy of referrer (giving less weight to concerns from neighbours or family members).

There was also a recommendation for Cambridgeshire Constabulary to provide assurance about improvements to internal system checks regarding the allocation, grading and sharing of domestic violence reports with other agencies.

The report also asks Children’s Social Care to provide assurance that children are both seen, and spoken to and others with parental responsibility, who are not resident in the family home, should be made aware of agency concerns.