Coroner ‘utterly bewildered’ at decision to discharge baby who later died from serious head injury

A baby girl who died from a serious head injury after being found unresponsive at her home was unlawfully killed, a coroner has ruled.

Healthcare professionals were concerned about 10-week-old Lily-Mai Hurrell Saint George being discharged from hospital and into the care of her parents, an inquest at St Pancras Coroner’s Court heard on Monday.

Police said there was insufficient evidence to charge either or both of her parents – Lauren Saint George and Darren Hurrell – in connection with Lily-Mai’s death.

Lily-Mai died at Great Ormond Street Hospital in London on February 2 2018, after being found unresponsive by her parents at their home in Belmont Road, Haringey, north London, two days earlier.

At the time of her death, she had suffered 19 rib fractures, an injury to her leg “from forceful traction and twisting”, and a serious head injury, the inquest heard.

The court heard Lily-Mai was born premature and had spent the first two months of her life in Barnet Hospital (pictured), before she was discharged into her parents’ care on January 25 2018.

Sithembile Dzingai, a locality manager who dealt with allocating health visitors, said she attended a discharge planning meeting at Barnet Hospital on January 22 2018, where healthcare professionals discussed concerns about the mother’s attachment and bonding with Lily-Mai.

In a statement read out in court, Ms Dzingai said the hospital ward were concerned that the parents did not visit or call to check on Lily-Mai’s condition for three or four days.

A referral was made to a social worker, Ms Dzingai said, adding that there were concerns with the baby being discharged with “no robust plan in place to support the parents”.

She said: “In my 12 years as a health visitor I’ve never had such feeling of anxiety about a case as I did about Lily-Mai being discharged in this way, because there were a number of concerns.”

Alberta Nyantakyi, a health visitor based at Laurels Healthy Living Centre run by Whittington Health NHS Trust, told the court she visited the family after Lily-Mai was taken into her parents’ care.

After she was repeatedly asked by senior coroner Mary Hassell whether she felt Lily-Mai was safe being left with her parents, Ms Nyantakyi said “no”.

She said she contacted social worker Theresa Ferguson and expressed her concerns about the baby’s safety, stating that she did not think it was the right decision for Lily-Mai to be discharged back to the care of her parents.

Ms Ferguson, from Haringey children’s services, said she made a referral for a legal gateway meeting which subsequently took place on January 31, where it was agreed the parents would go into a mother-baby placement.

Ms Ferguson said she visited the parents on that day, where Ms Saint George got “frustrated and angry” about the mother-baby placement, while Mr Hurrell was “calm and ordered” with Lily-Mai swaddled inside his jacket.

That night, Lily-Mai was taken into hospital, and died two days later.

When asked by the coroner whether she felt Lily-Mai was safe being left with her parents, Ms Ferguson said: “I didn’t think there would be immediate harm.”

But she added: “I was really worried about her.”

The inquest heard Lily-Mai’s cause of death was a head injury caused by shaking and impact, and that the level of force was significantly greater than what would be termed as rough handling.

On April 18 2018, the Metropolitan Police said a 20-year-old man and 21-year-old woman were arrested on suspicion of murder in connection with Lily-Mai’s death and were released on bail.

Appearing at the inquest hearing by videolink, Detective Sergeant Ian Valentine, of Metropolitan Police, said: “The case was reviewed but there was insufficient evidence to charge either parent or both.

“We have explored every possible avenue.”

Ruling that Lily-Mai was unlawfully killed, Ms Hassell said: “I am entirely convinced that Lily-Mai had died as a consequence of injuries that were non-accidental, given the force that I’ve heard would have needed to be applied to suffer these injuries.

“I am entirely satisfied Lily-Mai was unlawfully killed.

“I have heard the evidence of several professionals who were charged with taking care of Lily-Mai, that the doctors and nurses at Barnet Hospital were extremely concerned about her and that they did not believe it was safe for her to be discharged to the care of her parents.

“And yet Haringey children’s services did facilitate that discharge, and that is utterly bewildering to me.

“This is a very sad story.”

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