Questions need answering.
If the correct information had been passed on between the relevant agencies, could the injury to this child have been prevented?
It states in the report there is a well-known link between domestic violence and risk to children. If this is the case, why was it not identified sooner in this case?
Did the social worker, in light of the history of domestic violence, investigate the father's potential harm to his children?
If not, why not?
The parents made numerous visits to A&E instead of a GP to access health care for their children and a pattern was spotted and reported to the Primary Health Care team. When was this? What action was taken?
Why was this information not analysed properly? Why was communication limited?
In the cases of Aaron O'Neil, Alexander Gallon, Amy Charlton, and the cases in 1998 and in 2001, communication between the agencies was identified as failing. Why are the same criticisms being made time and again?
The serious-case review recommends that concerns shared by other professionals must be recorded and followed up. What concerns were there?
The review said all GP practices should set up a protocol relating to who has access to electronic records and the format for capturing social history and any cause for concern. Were these causes for concern not recorded in this case?