Page last updated at 12:47 GMT, Friday, 30 April 2010 13:47 UK

Child's death 'not preventable'

Zoe-Ann David
Zoe-Ann David's body was discovered at her home in Newport

A review into the death of a girl smothered by her mother in Newport says it could not have been "predicted or prevented" by the agencies involved.

Zoe David, aged 34, killed her daughter Zoey-Ann during a mental breakdown and has been detained indefinitely in a psychiatric hospital.

A Serious Case Review has however made 24 recommendations.

It involves improving procedures at agencies in Newport and Hammersmith and Fulham where they previously lived.

David admitted manslaughter on the grounds of diminished responsibility at Cardiff Crown Court in December.

Her daughter's body was found in a bedroom at their home in Bideford Close last June.

The Serious Case Review by the Newport Safeguarding Children Board - which refers to Zoey-Ann as Child One - said David had a difficult childhood and was treated for anxiety and depression when her first child was born.

It states she had a violent relationship with the father of Zoey-Ann.

Zoey-Ann was placed on the child protection register for neglect in 2007 after the family moved to the city from London.

She was de-registered in September that year based on her good health and development.

These were clearly a set of unfortunate circumstances that no one could have foreseen
Stewart Greenwell, Newport Safeguarding Children Board

The report said the decision to remove her from the register was "premature" but "probably made little difference".

It said there was an oversight that in Newport no one suggested seeking advice from the community mental health services.

The report states they might have been able to suggest ways of exploring the true extent of her mental health or assist her with her anxieties.

But it adds even if she had received a full psychiatric assessment followed by appropriate diagnosis and treatment, it is impossible to state in retrospect whether this would have reduced the likelihood of her harming her daughter.

It also states a social worker allocated the case was inexperienced and received no child protection training, had too high a case load and did not receive the managerial oversight needed due to staff vacancies.

The report concludes: "The death of child one would appear to be a sad, tragic event, which could not have been predicted or prevented by any specific action or intervention from any of the agencies."

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

"There were some shortcomings from a number of services in their contact with the family but it is encouraging that all agencies have accepted the recommendations and are already implementing the necessary changes."

During December's hearing the court was told that David acted after her daughter said she wanted to "go home", which she interpreted as "take me home to heaven".

She was detained under the Mental Health Act 1983 as a continuing risk to herself and family members.

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