Doctors in the dock for murder of baby Alexis

• Alexis has haemorrhages in both eyes but warning signs were not acted upon. Picture: PA

Simpson, 29, was found guilty of murdering the six-week-old daughter of his former girlfriend at the High Court in Aberdeen yesterday.

His attacks left the baby with brain damage and broken ribs, the court heard.

However, the failure of medics to protect Alexis has prompted calls for changes in Scotland's child protection system, in the same way the Baby P case led to changes in the law south of the Border.

Lord Uist, who sentenced Simpson to life and at least 20 years in jail, took the unusual step of publicly criticising the care she received at Woodside Medical Group in Aberdeen, saying he had "serious concerns" that her death could have been prevented.

In particular, the court heard the baby had been prescribed three types of drugs by doctors over the phone without ever being examined in person, while signs of abuse were overlooked.

Murdo Fraser, the Scottish Conservatives' health spokesman, said: "These are very serious criticisms by Lord Uist of the way the health services operated.

"Clearly, there were serious failings in relation to this baby's treatment and lessons have to be learned from this case."

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He added: "The Baby P case down south led to substantial changes being made in the approach to children's health in such cases. The Scottish health authorities have to treat this case with a similar degree of importance and urgency."

The court heard how Alexis' mother, Ilona Sheach, 21, called the medical practice on a Thursday, with serious concerns about her daughter's health but was not offered an appointment until the following week.

When she was finally seen on 29 November, 2007, she was not referred to a hospital paediatrician, despite the baby having "haemorrhages in both eyes" – signs that should have alerted the doctor that abuse may have taken place.

Consultant neurosurgeon Dr Helen Fernandes told the court the explanation given for these injuries "could not possibly be an explanation and that baby Alexis should have been referred to a paediatrician" straight away.

Lord Uist said: "I consider that there are two matters which call for an inquiry, with a view to preventing a tragedy such as the one that occurred in this case ever occurring again."

One, he said, was that three separate drugs had been prescribed following a consultation over the telephone with her mother. The judge said: "Expert medical witnesses expressed surprise at this, and so do I. More-over, it must be a matter of concern that a young mother who was seriously concerned about her baby's health and sought an appointment with a doctor on a Thursday was offered one only for the following week."

He said the practice's appointments system "may require urgent review".

Referring to the examination on 29 November, he said: "Nothing was done about possible signs of non-accidental injury, namely subconjunctival haemorrhages in both eyes."

A consultant paediatrician said in evidence that it would have been best for the GP to have phoned paediatricians for a consultation.

Lord Uist said: "Had that been done, baby Alexis would have been admitted to hospital more or less immediately.

"Whether the death of baby Alexis could have been prevented had she been so referred is a matter which, in my opinion, merits a very full inquiry.

"The training of GPs, and also health visitors, to detect signs of non-accidental injury may be a matter that requires further consideration."

The Crown Office has instructed a fatal accident inquiry to be held into her death.

NHS Grampian has said it will consider Lord Uist's comments carefully and "fully embrace any learning from this tragic case".

The death of 17-month-old "Baby P" – Peter Connolly – who suffered 50 injuries at the hands of her mother's boyfriend, Steven Barker, and his brother, Jason Owen, led to three inquiries and a nationwide review of social service care.

A Scottish Government spokeswoman said: "We extend our deepest condolences to the family of Alexis Matheson. We continue to monitor the situation very closely, and will await the findings of the fatal accident inquiry. Following this, we will work with the health board to determine any necessary changes and ensure that any lessons are learned."

An NHS Grampian spokesman said: "NHS Grampian and the Woodside Medical Practice would like to extend their condolences to Alexis' family. We understand that Lord Uist has issued a statement that it is critical of perceived failings in the care given to Alexis. We will consider these comments very carefully.

"We are committed to improving the quality of services that patients receive and will fully embrace any learning from this tragic case."

Simpson was charged with assaulting Alexis on various occasions between 8 November and 9 December, 2007, seizing hold of her, shaking her and compressing her chest, leaving her so severely injured that she died in hospital in Edinburgh.

He tried to blame Ms Sheach, claiming she played a game called "fishy" when she would lie on her back and rock the baby while she held her by the ribs.

She denied this in court and, speaking after the verdict said: "I now have to come to terms with the fact that he took Alexis' life from me and the fact he covered up for his actions by manipulating everyone he came into contact with. At first, when Alexis died, I didn't want to believe that anyone could do that sort of thing to a baby and I certainly didn't want to think Mark could – I wanted to believe it was a medical issue.

"I trusted Mark because he seemed to know what he was talking about, and I accepted his advice when I had concerns about Alexis."

She added: "It's now obvious to me that Mark said whatever suited him and that he was covering up for the things that he had done to Alexis.

Throughout our time together, he never once mentioned any concerns he had with my handling of Alexis and knowing what he has now said, having taken almost three years to dream this up, really sickens me.

Thankfully, the jury saw through his lies and convicted him."

Detective Inspector Richie Guild said: "Evidence heard during the trial indicates there were at least three distinct ages of rib fractures and that Alexis' brain had suffered at least two episodes of trauma. It's clear from these injuries that Alexis was assaulted repeatedly and her life was squeezed and shaken from her at the hands of Simpson."

Lord Uist told Simpson, who had previously admitted trying to groom young girls over the internet: "This crime did not consist of a single incident arising from a sudden loss of temper on your part but of a repeated course of violence directed at a wholly defenceless and vulnerable baby whom you should have been caring for and protecting.

"How you were able to act in such a wicked and abhorrent manner towards a helpless infant is beyond the understanding of all right-thinking people.

"The pain and agony which baby Alexis must have suffered as a result of the injuries which you inflicted upon her are unthinkable."

Simpson assaulted Alexis at his home while she and Ms Sheach were living there. After a trial lasting 28 days, a jury unanimously found him guilty of murder.

Anne Currie, area procurator fiscal for Grampian, said: "Mark Simpson had subjected Alexis to as many as 40 injuries over a number of weeks. It is hard to believe that anyone could even contemplate treating a tiny, defenceless baby in this way."