Chances missed to save Cardiff toddler killed by father, review finds

Chances were missed to protect an 18-month-old girl murdered by her father less than a fortnight after he and his husband adopted her, an independent review has revealed.

Hospital staff did not spot a fracture to Elsie Scully-Hicks’s thighbone, and social workers and health professionals did not record a large bruise to her forehead, the review said.

Elsie suffered a series of injuries in the months before the fatal attack at the family home in Cardiff in which the former fitness instructor Matthew Scully-Hicks shook the child and may have banged her head against a hard surface. But Scully-Hicks’s explanations that she had fallen were believed.

The child practice review said: “There were opportunities to consider the pattern of the child’s injuries and accidents that were not explored.” It added: “No safeguarding concerns were raised.”

Scully-Hicks and his husband, Craig, were regarded as “welcoming people with valuable childcare experience”, the report said. It concluded that assessments of the couple during the adoption process were “robust, detailed and comprehensive”, but it said: “There was a lack of professional curiosity regarding the child’s experiences and injuries.”

Matthew Scully-Hicks

Matthew Scully-Hicks was jailed for life last year. Photograph: South Wales Police/PA

At the time of the child’s death it was difficult to draw a timeline of the child’s medical history partly because a number of different IT systems were involved and Elsie was known by four different combinations of the birth and adopted name. “No one agency or worker held all the relevant information on this child,” the review said.

The review also highlighted that Elsie’s birth mother was not informed of her death for several months and said she felt she received information about what happened from several sources in an ad hoc fashion.

Elsie was placed with the couple in September 2015 by Vale of Glamorgan council in south Wales after being removed from her mother, who was a drug user. Scully-Hicks took full-time care of Elsie while Craig, an account manager, worked.

Last year Cardiff crown court heard that Scully-Hicks had complained in a series of texts that Elsie was a difficult child, describing her as “Satan dressed in a babygrow” and calling her a “psycho” and “monster”. He once wrote he was “ready to explode”.

The adoption was formally approved on 12 May 2016. Thirteen days later Scully-Hicks dialled 999 and said his daughter had collapsed. When paramedics arrived she was not breathing and was in cardiac arrest. She died four days later. She had suffered three separate areas of bleeding on her brain, retinal bleeding, a skull fracture and three rib fractures.

The review highlighted that in November 2015, Elsie suffered a leg injury, which according to Scully-Hicks happened when she fell from an activity table in the kitchen.

An x-ray was taken and a registrar saw a fracture just above her right ankle but missed a second break in her right thighbone.

The review said: “The omission of identifying the second fracture to the child’s upper leg on the x-ray was a missed opportunity to raise safeguarding concerns and instigate child protection procedures.

“If the original examination of the x-ray had identified both fractures, safeguarding concerns would undoubtedly have been raised and child protection procedures instigated … agencies could have reasonably and tangibly intervened.”

In December 2015 Elsie sustained a bruise to her forehead. Scully-Hicks claimed she had fallen as she pulled herself up on a toy kitchen. An adoption review took place at the time and Elsie was seen by her social worker, an adoption social worker and an independent reviewing officer. But the presence of the bruise was not recorded. Five days later a health professional also saw the bruise but did not share this.

The report said: “The observations and recording of the large bruise to the child’s forehead both by children’s services and health was absent. This resulted in the large bruise becoming ‘invisible’ to professionals and did not form part of building an overall picture of what was happening to the child.”

It added: “There is no evidence to suggest that any of the professionals working with the child considered these injuries together or what this could have meant for the child.” It meant that the final adoption hearing – the last opportunity for external scrutiny of the child – did not have the full details of the injuries the child suffered.

Eight agencies were involved in the review and nine recommendations were made including ensuring that a child who has been placed for adoption and arrives at hospital with an injury should be overseen by a paediatrician with safeguarding experience and training. It also said a timeline of all injuries suffered by a child placed for adoption – regardless of cause – should be created.

In November last year Scully-Hicks was jailed for life and told he would serve a minimum of 18 years.

Lance Carver, director of social services at the Vale of Glamorgan council, accepted the findings of the report and apologised for errors in Elsie’s case. “The findings do indicate that social workers and staff from all agencies saw the adoption as very positive,” Carver told a press conference in Cardiff.

“They perceived the adoptive family as a really positive solution for Elsie. The report identifies issues that ‘that positive lens’ meant that they were not looking in the way they should have been. That’s something as an organisation that we should have recognised and taken that fully on board.”

Carver said no disciplinary actions had been taken against any members of staff as the report did not “indicate that it would be appropriate”.


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