An independent review into the murder of a nine-year-old boy from Lincoln, killed by his grandfather, has concluded that it could not have been predicted or prevented.
As reported at the time, Stewart Greene was jailed for life and ordered to serve a minimum of 22 years after drowning his grandson Alex Robinson on December 23, 2014 while under his supervision at the boy’s home.
Courts heard Greene had been discharged from a psychiatric unit just 12 days before the incident and had been angry that his daughter Joanne would not allow him to move into her home.
Joanne had urged staff not to release him, but he was deemed not to be mentally ill but exaggerating symptoms to continue institutionalised life.
The findings of the review, commissioned by the Lincolnshire Safeguarding Children Board (LSCB) and published at the family’s request on December 16, determined “the only individual responsible for the tragic death is the maternal grandfather”.
Report author Ceryl Davies highlights the unusual aspect of this serious case review given the limited history of agency involvement with the boy and with the majority of agency involvement being with the grandfather.
Over several years prior to the tragic case, the grandfather presented as having fluctuating mental health needs.
In the six months preceding the boy’s death, the grandfather was admitted to an acute mental health unit for assessment by the Lincolnshire Partnership Foundation Trust (LPFT).
The report points to a number of learning and recommendations for practice, particularly for LPFT.
Chris Cook, Chair of the Lincolnshire Safeguarding Children Board, said: “This is a tragic case and we can only imagine the sense of loss the family must feel. Our thoughts are very much with the whole family and we thank them sincerely for their contributions to this review.
“The author of this report clearly identifies that the responsibility for the boy’s death lies with the grandfather.
“His actions were not as a result of any mental health illness and he made the decision on his actions and has found guilty and convicted of murder.
“However, these reviews can identify any improvements which are needed, which helps to consolidate good practice in safeguarding children and young people.”
Anne-Maria Olphert, Director of Nursing and Quality at LPFT, said: “Our thoughts are with the family and friends as the independent report concerning the serious case review is published.
“The report concludes that the only individual responsible for the death is the child’s grandfather who was convicted of murder in November 2015.
“However we accept there were opportunities for the trust to have better considered the risk he posed to the public, and we will be using the findings of the report to improve services.
“The report acknowledges that the trust has comprehensive policies, procedures and training in place. However staff did not comply to our policies and procedures in this case and we have taken steps to ensure staff follow good working practice and take advantage of training opportunities.
“We note the finding about the importance of hearing the voice of the family and we will work constructively with our staff to ensure that they take a more proactive approach in listening to family members.”