THE DEATH of a Newport tot could not have been “predicted or prevented” by any agency involved, according to a serious case review published yesterday.

Zoe-Ann David was found dead in her home in Bideford Road, Maesglas, on June 19 last year. A post mortem examination concluded she was suffocated.

The youngster’s mother, Zoe David, 34, was detained indefinitely under the Mental Health Act in December, after admitting manslaughter on the grounds of diminished responsibility. The court heard she killed the four year old while suffering from paranoid schizophrenia.

Following Zoe-Ann’s death, Newport Safeguarding Children Board conducted a serious case review which concluded her death was “a sad, tragic event, which could not have been predicted or prevented by any specific action or intervention from any of the agencies.”

Stewart Greenwell, Newport Safeguarding Children Board chairman, said: “These were clearly a set of unfortunate circumstances that no one could have foreseen.”

He said although there were some shortcomings in the contact some services had with the family, the agencies involved had accepted the report’s recommendations and were implementing necessary changes.

The report found the family was known to social services in London, where Zoe-Ann was on the Child Protection Register, but it was not until May 2007, two months after David moved, that Newport Children’s Services were informed and Zoe-Ann was placed on the Child Protection Register again.

The report stated that no core assessment and analysis of the needs of the family was completed, which led to the Child Protection Plan being a list of recommendations and activities rather than a list of what needed to be done.

It also describes an "oversight" in that no one suggested seeking advice from Community Mental Health Services who may have been able to suggest ways of exploring David's mental health while she was in Newport.

The report found that the social worker allocated the case was "inexperienced", had no child protection training, had too high a case load and did not have the required managerial supervision due to vacancies in the team.

It states that those who came into contact with David through Women’s Aid and other agencies described her as “a loving and ‘seemingly over fussy’ parent.”

A decision to remove Zoe-Ann from the register was made at a review conference in September 2007.

Between Spring 2008 and Summer 2009, the agencies that had contact with the family expressed no concerns over the care of Zoe-Ann or David’s mental health.

Just three days before Zoe-Ann’s death, her mother took her to the GP regarding a minor ailment and no concerns were raised over David’s behaviour or demeanour.

The report found that even if David had received a full psychiatric assessment and was treated, it is "impossible to state in retrospect whether this would have reduced the likelihood of mother harming her child."

24 recommendations in report

The report outlines 24 recommendations, which Newport Safeguarding Children Board will monitor.

Recommendations include: early involvement of specialist mental health professionals in families where borderline mental health needs are identified; social services departments ensure that all front line staff and managers receive training on the requirements for assessments held within procedures and guidance including child protection procedures; that family project officers will receive training in the recognition of mental health issues.