THE death of a five-year-old boy who was killed by his mother could not have been predicted or prevented, official reviews have concluded.
Tyler Warmington was stabbed by Emma Jackson at their home in Faringdon in March 2017. She was herself found by police with self-inflicted injuries.
Oxfordshire Safeguarding Children Board (OSCB) and Oxford Health NHS Foundation Trust both concluded nothing could have been done to have ‘predicted or prevented’ Tyler’s death.
In April 2018, Jackson was sent to a mental health hospital indefinitely after she admitted manslaughter by diminished responsibility.
Although Jackson had a long history of mental illness going back about 20 years, she had no record of violence before Tyler's death. Assessments carried out in the run-up to March 2017 found her mental health problems appeared to have reduced.
READ MORE: Mum sentenced for stabbing son to death in Faringdon
Oxford Health said official documents gave ‘no indication’ that professionals involved in Jackson’s case had ‘missed signs of a serious deterioration’ in her mental health or risk.
But it was found that Jackson, who is now 42, had appeared to be suffering from delusional thinking in January 2015. She said she worried her son would be lost to her and on a ‘small number of occasions’ had reported thoughts of killing him to ‘prevent others harming him’.
At the time, the pair lived in Swindon and had lived in South London at the start of Tyler’s life. They moved to Faringdon in June 2015.
Work will now need to go into ensuring people’s histories are transferred appropriately when they move around the country.
Mark Hancock, Oxford Health’s medical director, said: “[Transferring details] can be very difficult and I think that’s the issue. As the NHS we’re working on better systems of information and transfer of patient records when people move. That’s independent of this case – that’s something that the NHS has been working on for some time anyway.”
READ MORE: School called 999 on day five-year-old Tyler Warmington died, inquest hears
Dr Hancock said: “I think there’s also a question of ensuring that information summaries are given in a way that’s useful. A problem can be that if you send someone a case record, it doesn’t necessarily mean the next person who will see the patient will have the time to pick out the bit that’s important.
“In this case there was particular risk information that effectively was lost in the transfer between organisations.”
Richard Simpson, independent chair of the OSCB, said: “This is first and foremost a human tragedy when a young boy lost his life. We have conducted a thorough review that has led to recommendations and a comprehensive Action Plan.
“The tragedy is that despite many workers and agencies doing excellent work to support the family they were not able to predict and therefore prevent this loss of life. My thoughts are with the family at this extremely difficult time.”
Mr Simpson said OSCB has withheld details relating to three other serious case reviews because of fears children involved could be adversely affected if details were made public.
He said: “We would only withhold if it was protecting surviving people and surviving children. We will still look if we can do something, but we do have to protect vulnerable children.
“In terms of numbers, I can only talk of Oxfordshire Safeguarding Board but it’s very unusual for us not to publish.
“We work very hard to engage in an open way and we’re here talking about a difficult case.
“People say: it’s easy because [today’s] report says it wasn’t predictable or preventable. But in some cases, that’s more difficult [to publicise], because actually a number of people did really well [in their jobs] – but a child died. We would always wish to publish.”
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