Lily-Mai George
PFD Report
Historic (No Identified Response)
Ref: 2021-0033
Coroner's Concerns (AI summary)
Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
View full coroner's concerns
Many healthcare and other professionals expressed the view that Lily-Mai should not be discharged into the unsupervised care of her parents, but Haringey Children’s Services nevertheless facilitated that discharge from hospital on Thursday, 25 January 2018. Lily-Mai suffered her fatal injuries six days later.
A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit, with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made.
If you have not done so already, I encourage you to listen to the recording of the inquest so that you have a starting point for consideration of the actions and omissions of Haringey Children’s Services.
A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit, with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made.
If you have not done so already, I encourage you to listen to the recording of the inquest so that you have a starting point for consideration of the actions and omissions of Haringey Children’s Services.
Sent To
Response Status
Linked responses
0 of 1
56-Day Deadline
7 Apr 2021
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 19 April 2018, I commenced an investigation into the death of Lily-Mai Hurrell Saint George, aged 10 weeks. Following a lengthy police investigation, the coronial investigation concluded at the end of the inquest on 8 February 2021. I made a determination at inquest that Lily-Mai had been unlawfully killed.
Circumstances of the Death
Lilly-Mai was hurt by an adult with such force that she suffered 19 rib fractures, other broken bones, and a severe head injury from which she died. This took place on the afternoon/evening of Wednesday, 31 January 2018, while she was in the exclusive care of her parents.
Copies Sent To
Haringey Safeguarding Children Board
Haringey Child Death Overview Panel
Barnet Hospital
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.