A report published on Friday (FEB 28) has revealed a litany of agency failures in the case of an Erith baby’s “preventable death” from rickets and admits “a number of opportunities to protect the baby were missed”.
Parents Nkosiyapha Kunene, 36, and Virginia Kunene, 32, were Seventh Day Adventists and refused medical treatment on religious grounds until five-month-old Ndingeko died of florid rickets in June 2012, bought on by severe vitamin D deficiency.
The report investigates the “consistent lack of professional curiosity” in the family from authorities including Bexley social services and Darent Valley Hospital - although a safeguarding representative has defended these services to News Shopper.
The 32-page document describes “extraordinarily optimistic” health visitors, lack of monitoring and communication between agencies, failure of the GP to promote vitamin D, and staff confusion over forms.
The parents were jailed for more than five years in total for gross negligence manslaughter but the authorities were also criticised in court.
‘Lack of agency checks’
The report by Bexley’s Local Safeguarding Children Board said: “This was a preventable death and a number of opportunities to protect Baby F were missed.
“The GP should have been aware of the importance of breastfeeding mothers to take vitamin D supplements and this would have been even more relevant in Mrs F's case.
“The health visitor’s visit was extraordinarily optimistic and the parents were seen to be very co-operative.
“There was a lack of any agency checks, which if undertaken is likely to have provided a more complete picture of the risks."
‘Communications between professionals does not appear to have been effective’
Baby Ndingeko had not been seen by any professionals for three and a half months by the time of his death.
The report said:“The nature of the spiritual beliefs and sanctions articulated by his mother were extreme and should have raised both concern and questioning.
“There was a consistent lack of professional curiosity and challenge to both parents and other professionals.
“During this period (after Ndingeko was born) communications between professionals does not appear to have been effective in particular between the hospital, the GP and the health visitor.”
'Little evidence of engagement'
It is also revealed Ndingeko’s father’s job as a nurse at King’s College Hospital was not flagged to authorities until September 2012 – three months after the baby’s death.
The report said: “There were three separate occasions when concerns should have been raised this included the rapid response meeting.
“It is unclear why there was a break down in multi agency working in this respect, evidence suggests whilst agencies reference that they recognise and understand the role of the local authority designated officer there is little evidence of engagement.”
Confusion over form-filling also appeared to have played a part.
The report said: “Junior staff do not appear to have understood the differences between a social care referral, the concern and vulnerability form and a Common Assessment Framework (CAF)."
However Barbara Trevanion, independent chair of Bexley Safeguarding Children’s Board, told News Shopper lessons had been learned from the situation and improvements were already in place.
She said: “It was a very unusual case which highlights the importance of Vitamin D, particularly given the mother was vegan.
“My health colleagues have already done a lot of work on promoting the importance of this vitamin as a direct result of this case.”
Ms Trevanion believes the balance between family privacy and protection was problematic.
She said: “Everybody has a right to protect their religion but not to the extent that it puts lives at risk.
“People are very respectful of others’ religion and tradition and sometimes that can cloud the rights of the child.
“The father was a nurse as well which felt like reassurance.
"However there had been early indications there was some risk involved.”
Ms Trevanion said Bexley’s Council’s children’s services have come a long way since Ofsted deemed them "inadequate" in a number of key areas in August 2012 – two months after Ndingeko’s death.
She said: “We are doing our best to implement the report’s recommendations and we have made real improvement in Bexley since the inspection.
“We all do our best to make sure those children are safe and this goes for the community as well.
“If people are worried they should visit the safeguarding website to register concerns."
For more information, visit bexleylscb.org.uk