Review found “learning points” for care services after death Balderton one-year-old Kenny-John Elijah Becket-Ward, inquest hears

A review carried out into the death of a one-year-old baby has found ‘mismatch’ in how social care and health services responded to the case, an inquest has heard.

Today was the second day of an inquest into the death of Kenny-John Elijah Becket-Ward, who was found unresponsive by his mother, Chantelle Beckett, at their home in Balderton on March 7, 2024.

It is scheduled to conclude tomorrow, with the final evidence from witnesses given today. Yesterday the inquest heard evidence from Detective Sergeant Laura Gooch and nurse Kate Robinson.

As no cause of death has been ascertained by the Home Office post-mortem, coroner Dr Elizabeth Didcock explained she was examining if more could have been done to care for the child known as Kenny and lessen risk factors for sudden death prior to his death — even if it is impossible to say if it would have prevented it.

Risk factors in Kenny’s case included his premature birth and related underlying medical conditions, and his home living situation, which was frequently unhygienic. The inquest had previously heard that at the time of his death the family’s home had dirty nappies all over, faeces on the floor, dirty pots and food waste, and a fly infestation in the kitchen.

The final witness for the day was DCI Jo Elbourn, of Nottinghamshire Police, who chairs the safeguarding partnership which includes police, health authorities, social services, and education bodies among others, and which led the rapid review into Kenny-John’s case.

Reviews are carried out into cases with concerns of neglect — which in this case the coroner described as “serious, longstanding, and became more focussed in the final months”.

The review aimed to find aspects of his care which could have been better, in order to help services learn and improve outcomes for other children in similar situations.

Three main learning points were identified, DCI Elbourn explained. The first was a recommendation to better work with families of premature infants before discharge to insure their understanding of the care required.

In Kenny’s case, with his additional vulnerabilities of his health conditions and difficult living situation, DCI Elbourn noted that “not all partners understood that equally or clearly”.

The second area of learning related to better use of the ‘neglect toolkit’ available to services, which had not been used in Kenny’s case, and was across the board “not consistent”.

The third learning point related to services’ differing views of the situation and the need for meeting between these services to help them develop strategies to move forwards.

DCI Elbourn said there was a “mismatch” between how health and social care services wanted to progress the case.

Evidence heard earlier in the day from the family’s assigned social worker, who had been involved with them since 2022, showed that there were differing experiences between agencies when visiting the family’s flat on multiple occasions.

On an occasion when police visited the flat to arrest Kenny’s father, they noted extremely poor conditions, but when social services visited later the same day, it was significantly improved and not considered an immediate risk.

Notes from visits showed the state of the flat fluctuated, and while aspects such as stained carpets remained consistent, it was sometimes tidy but other times issues such as faeces on children’s bedsheets, piled up bags of unwashed clothes, and a smell of cannabis were noted.

However it was suggested the extremely poor condition of the flat at the time of Kenny’s death was a “sudden change” and “radically different” from how it had looked just a few weeks prior.

The family also missed numerous medical appointments in the months up to Kenny’s death, despite social services’ attempts to ensure they had the funds and ability to attend them, and discussing this with them in meetings — while the coroner noted medical professionals had become increasingly concerned about the non-attendance of appointments.

Giving evidence, consultant paediatrician Dr Amol Chingale, who had been responsible for Kenny’s care at Lincoln County Hospital since his birth, said he was “quite alarmed” by the non-attendance, and had “concerns boiling up in [his] mind”.

He had also prescribed antibiotics for Kenny after test results came back showing signs of a chest infection following his final successful appointment on January 19, 2024, and while a system error had meant this prescription has never come to fruition, Chantelle had told the social worker Kenny was on a course of antibiotics which she had been to the GP to pick up — despite no record of the prescription ever reaching the GP nor of her attending the surgery.

Dr Chingale believed it was vitally important for Kenny to be seen by a medical professional to keep track of his condition, and said he may have admitted him as an inpatient in early 2024 based on the baby’s response to the antibiotics he believed he had received, and on the basis of the parents’ “non-engagement”.

The social worker also suggested Chantelle did not appreciate the severity of her child’s health concerns, despite his low weight and respiratory issues, saying she didn’t see why she needed to attend the hospital on January 19. He also suggested her priority at the time was Kenny’s father’s release from prison in early February.

The coroner suggested that by February there would have been “serious concerns about his condition”, but that it could not be said that him being seen or admitted could have prevented Kenny’s sudden death.

Closing the inquest for the day ahead of her conclusion tomorrow, Dr Didcock said she had “risk factors but not cause” for the death, and that she would consider if enough was done in the months leading to Kenny-John’s death and also if she could make any progress in the death being of natural causes as two of Kenny-John’s father’s relatives — one a sibling and the other a more distant relation — had died suddenly as babies.

She added: “For any family this is devastating, absolutely devastating.”