Health professionals ‘could not have prevented’ murder of six-week-old baby

THE murder of a six-week-old baby by her mother’s boyfriend could not have been prevented by health professionals, an independent review has concluded.

• Mark Simpson sentenced to life imprisonment after being convicted of the baby’s murder

• Baby had been prescribed medicine by phone without ever being examined by doctors

• Chief officer of Tayside community justice authority makes eight recommendations during ‘significant case review’ including review of GPs prescribing drugs over the phone

An investigation into the murder of Alexis Matheson was ordered by child protection services after a High Court judge voiced concerns about the care she had received at the hands of a GP practice in the days leading up to her death.

Mark Simpson, 32, was sentenced to life imprisonment in November 2010 and told he would serve at least 20 years after he was convicted of Alexis’s murder.

At the conclusion of his trial at the High Court in Aberdeen, the judge, Lord Uist, took the unusual step of publicly criticising the care the “helpless infant” had received at Woodside Medical Group in Aberdeen, saying he had “serious concerns” that her death could have been prevented.

The court was told the baby had been subjected to a series of brutal attacks that had left her with brain damage and broken ribs. She had sustained as many as 40 injuries over a number of weeks.

She had been prescribed three types of drugs over the phone by doctors without ever being examined in person, while signs of abuse had been overlooked.

But yesterday, a “significant case review” into the baby’s death, commissioned by the North East Scotland Child Protection Committee, cleared health professionals of blame.

Howard Llewellyn, the chief officer of Tayside community justice authority, who headed the review, wrote: “In considering the appropriate recommendations, I have considered the question of whether Alexis’s death could have been prevented had signs of non-accidental injury been detected earlier.

“I conclude that her death was not predictable from the information available to practitioners. Whether it would have been preventable is more problematic, given the evidence presented at trial.

“I conclude that, although her injuries may have been treatable in the few days before her death, her survival was possible rather than probable. I do not therefore conclude that her death would have been prevented

“I found no evidence, despite increasing demands, of significant staffing or resilience difficulties within the midwife service, the health visiting service or in the GP practice in question. I found the actions taken by health visitors to engage with Alexis and M [the baby’s mother, Ilona Sheach] were persistent and professional.”

Mr Llewellyn went on: “I found no evidence to indicate that there were any significant or mounting concerns being expressed by anyone either over Mark Simpson’s involvement with Alexis; as to M’s parenting abilities or as to Alexis’s health.”

Mr Llewellyn made a series of recommendations. These included a call for a review of GPs prescribing drugs by telephone for babies and a call for children to be “flagged” and referred to the health visitor service when he or she is presented for consultation by telephone and an appointment is offered and rejected.

He also recommended a review of GPs’ and health visitors’ training and experience to ensure that practitioners, whether full-time or part-time, are trained, and regularly refreshed, in recognising the signs of non-accidental injuries.

Elinor Smith, vice-chair of the protection committee and director of nursing for NHS Grampian, said: “The death of Alexis was a tragedy. All the staff who knew Alexis have been deeply affected by her death.

“While Mr Llewellyn has come to the conclusion that her death couldn’t have been prevented, nevertheless he has made recommendations for improvement and we have already been addressing some of these recommendations and will continue to address them.

“Lessons have already been learned. We are certainly not complacent and we certainly recognise that we have got other things that we need to keep working on. The improvements being made will benefit children in the future.”

NHS Grampian said: “Woodside Medical Group have taken part in the review process with other agencies involved and note the recommendations made by Mr Llewellyn.

TIME LINE

26 OCTOBER, 2007 Ilona Sheach gives birth to Alexis.

8 NOVEMBER Alexis’s abuse at Simpson’s hands begins.

22 NOVEMBER Ms Sheach calls the Woodside Medical Group with serious concerns about her baby daughter.

29 NOVEMBER Alexis is examined at Woodside Medical Group. She is not referred to a paediatrician, despite signs of abuse.

9 DECEMBER Simpson claims to have found Alexis “limp and lifeless” in lounge.

10 DECEMBER Alexis dies at Royal Hospital for Sick Children in Edinburgh.

18 APRIL, 2008 Couple are charged with murder. Charges against Ms Sheach are later dropped.

26 NOVEMBER, 2010 Simpson convicted of murder.