Neath and Port Talbot Watchdog (NPTW)

The fight for justice against corruption is never easy. It never has been and never will be. It exacts a toll on our self, our families, our friends, and especially our children. In the end, I believe, as in many individual cases, the price we pay is well worth holding on to our dignity. Free Tommy Robinson
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'Child Deaths'
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Child Sofia aged 1 Year

Tri-Borough (Hammersmith and Fulham, Kensington and Chelsea, Westminster) Social Services.

Mother received services from 7 local authorities before the authorities lost contact?


Death of a 1-year-old girl in October 2013 from asphyxiation due to choking on food. Autopsy findings found Sophia was significantly underweight and there were signs of historic untreated injuries. Parents may be charged with neglect.

Background: mother had no permanent address and received services from 7 local authorities. Sofia and her mother were known to medical staff, social workers, housing professionals and the police. There were no signs of physical injury or neglect and Sophia was not considered to be at continuing risk of significant harm. When Sophia was 3-months old they moved and were not seen by a professional until her death. Father was allegedly living overseas but was later found to be living with the family illegally on an expired visa.

Learning: findings include: complexity of legislation and lack of understanding around provision of housing and benefits for a European National; homelessness during pregnancy not being a trigger for assessment and not being considered a safeguarding issue after birth; assessments made on mother's intention rather than child's experience; strategy discussions conducted via telephone excluding some agencies; a focus on physical manifestations of neglect over more complex indicators; and avoidant families becoming ‘lost’ to services.

Model: SCIE's Learning Together systems model

Read the overview report