Source: Birmingham Safeguarding Children Partnership published on this website Thursday 5 June 2025 by Jill Powell
Child Safeguarding Practice Review: Child A BSCP 2022-23/04 published 4 June 2025
Introduction and background to the review:
“This report sets out the findings and learning from a Child Safeguarding Practice Review (CSPR) that was commissioned by the Birmingham Safeguarding Children Partnership.
“A Rapid Review was triggered following information being provided to Birmingham Children’s Trust by Somerset Children’s Social Care in December 2022. This information highlighted that while Somerset Children’s Social Care were taking legal action to remove a three-month old child from parental care, the child’s parents disclosed that an older child of theirs had died around January 2020 whilst they were living in the Birmingham area, and that they had buried the child’s body in the garden of the property.
“West Midlands Police subsequently recovered a body; the age of the deceased child was thought to be between three and four years of age. The findings of the post-mortem are inconclusive in terms of both cause of death but also age at time of death.
“As part of the Rapid Review, it was confirmed that the father had a third child, aged five years, living in London with another female partner. To protect the anonymity of three children at the centre of this review, they have been given pseudonyms; the deceased child discovered in Birmingham will be known as Child A, the three-month old baby located in the Somerset area will be known as Sibling B, the five-year-old child living in the London area will be known as Sibling C. Given the circumstances in Somerset and significant harm suffered by Sibling B, alongside the suspicious circumstances surrounding Child A’s death, abuse and neglect of Child A could not be ruled out; therefore, based on statutory guidance the Partnership determined that a CSPR should be undertaken. West Midlands Police investigated Child A’s death; these investigations resulted in a criminal trial which concluded with both parents being found guilty of causing or allowing the death of a child as well as perverting the course of justice. The father was sentenced to 24½ years and his mother to 19½ years.
“The following relevant remarks were made by the sentencing Judge at the trial’s conclusion, and which places both Child A and Sibling B’s daily life in context, and help us appreciate Child A’s lived experience in the remaining months and weeks of his life: ‘… You wilfully neglected both of them in that you failed to provide them with adequate amounts of properly nutritious food and you failed to obtain necessary medical attention for them. Child A died as the result of your wilful neglect of him. Sibling B has been left with very significant health difficulties … that will require assistance and medical supervision for the rest of his life. … It is difficult to imagine a worse case of neglect than that which the court has encountered in your case. Your motivation for acting as you did was your prioritisation of your distorted system of beliefs over their welfare. You were prepared to live with any consequences which flowed from your adherence to those beliefs, including the disability or death of the children. Postmortem examinations revealed ‘…His bones were thickened and porous and largely made up of poor-quality bone. He had insufficiency fractures to his shins, ribs, and radius. These would have been painful when they were caused and 1 would have caused further pain each time the broken ends of the bone rubbed against one another before they reunited. These fractures were all caused at least three weeks before death. There was overwhelming evidence that he had rickets … anaemia and [vitamin] deficiency. He had obviously been malnourished in life. … In life he had truly appalling dental health. His gums would have bled frequently. He would have experienced pain on eating anything hot, cold, or sweet. There would have been acute pain on biting and some constant dental pain. His sleep would almost certainly have been interrupted. He was severely stunted in his growth. At almost 4 years of age, he was buried in the clothes of an 18-month-old and was no taller in all probability than the average 14-month old child. … You decided not to help him because, to you, at that time, remaining true to your beliefs was more important than his welfare. …’. ‘…Once they found Child A's body…, [the father], performed CPR on him but to no avail. They then waited with the body for eight days in the hope that he would come back to them, and then buried him in the backyard. He said they had a belief in reincarnation and that they thought that Child A would come back because his work on earth was not yet done. They did not report his death to the authorities because such things as death were only to be shared within their community.
“The focus of this review is to capture learning about how Child A became lost from professional view and oversight. In doing so, the review will examine agency contact with Child A and family members across different local authority areas in what were initially considered to be unconnected episodes. It is only now that hindsight has enabled connections to be made between all these episodes and to build a bigger picture, highlighting the importance for all professionals to be robust in their assessment activity, triangulate information to eliminate doubt or confusion, ask searching questions, share information and be tenacious in their efforts to understand the impact of culture and beliefs on children’s safety and welfare. The review and the criminal proceedings highlighted that professionals ceased to have any contact with Child A due to the parents opting out of contact with agencies and seeing agency involvement as intrusive. The observations of Child A between his birth in 2016 and up to August 2018 carried out by the midwife, health visitor, Waltham Forest social worker, police and Children’s Centre workers had not given rise to any cause for concern about his development. It is now clear that there was a catastrophic deterioration in his health and welfare between that point and his death in early 2020 due to the appalling neglect by his parents. The last months of Child A’s life must have been unimaginably sad and painful given his health and medical needs.”
