A ten-week old baby girl was killed unlawfully after an “utterly bewildering” decision by child services to discharge her to her parents, a coroner has ruled.
Lily-Mai Hurrell Saint George was taken to North Middlesex University Hospital and then to Great Ormond Street Hospital where she died on February 2, 2018, three days after being found unresponsive at home.
Her injuries and bruising were consistent with “shaking type injuries”, the inquest heard.
Her parents Darren Hurrell, then 21, and Lauren Saint George, then 20, were arrested on suspicion of her murder on April 16.
St Pancras Coroners Court heard the case was reviewed by the Crown Prosecution Service and there was “insufficient evidence” to pursue charges against either parent.
A coroner ruled today that Lily-Mai was killed “by an adult” while in their care.
The burden of proof at inquest (on the balance of probabilities) is different from the criminal burden of proof (beyond reasonable doubt).
Recording a conclusion of unlawful killing, senior coroner Mary Hassell said: “A ten-week old baby was injured by an adult so that she suffered 19 rib fractures, other broken bones and a severe head injury from which she died.
“This took place in the late afternoon or early evening of the 31 January, 2018 while Lily-Mai was in the care of her parents.
“Many healthcare and other professionals expressed the view that Lily-Mai should not have been discharged into care of her parents but Haringey Children’s Services nevertheless facilitated her discharge from hospital on the 25 January 2018.
“I’m so sorry for the loss of this otherwise healthy baby girl.”
The inquest heard Lily-Mai was born prematurely at 31 weeks and spent the first two months of her life in hospital.
She was discharged to the care of her parents at a flat in Tottenham on January 25, but was taken back on January 31 in a “critical and life threatening” condition.
Mr Hurrell said he had woken up to Lily-Mai’s crying but went over to her cot to check on her and realised she had stopped breathing.
He claimed her fractured ribs may have been caused by him giving her CPR.
He told the inquest: “I woke up, I went to the cot because she was crying and she just stopped crying for about five minutes.
“I went to the cot to see if her mother needed any help and she just wasn’t breathing.
“Lauren was in the hallway or in the kitchen either coming in with the bottle or in the kitchen getting the bottle.”
In a statement to the inquest, Mr Hurrell said he had grabbed Lily-Mai’s ankle as she was able to fall off a bed, and that her pram had fallen over on the bus a few days before her death.
Both parents described that Lily-Mai would scream for hours, sleeping only in the day time and not at night.
They also described multiple incidents of her turning blue and floppy, but said they thought it was because she suffered from anemia.
Ms Saint George was asked to give evidence at the inquest but responded to all questions: “I stick with all statements previously said.”
Britain’s top forensic pathologist Dr Nathaniel Cary said Lily-Mai had multiple bruises over her face, neck and chest as well as multiple bleeds on the brain, 19 rib fractures and a fracture to the leg.
He said it was his opinion the fractures were “shaking type injuries” caused by a “gripping of the chest, squeezing and shaking backwards and forwards”.
Dr Cary said: “The formal cause of death I give is head injury which encompasses both shaking and impact as a cause of that head injury.
“This is not ordinary trauma from normal handling.”
The inquest heard there were some concerns about Lily-Mai’s parents and ability to look after her.
A plan was put in place to assist them before she was discharged.
It was said Ms Saint George has another child born before Lily-Mai, who she does not have responsibility for.
Health visitor Ms Nyantakyi told the inquest she did not notice bruising on Lily-Mai’s body during her visits, but was concerned that Mr Hurrell had left her on the edge of a bed during a visit.
Social worker Teresa Ferguson said she was “really worried” about Lily-Mai’s case, and health professionals also disagreed with the discharge.
After being born prematurely, Lily-Mai had to undergo several blood transfusions in hospital and her parents had been warned to watch out for signs of her “going floppy”.
She said: “I was really worried about her not picking up on her health needs or an accident.
“Like her falling off the bed and them both being on their phones.”
Ms Ferguson visited the family on the day Lily-Mai was taken to hospital, and said she did not notice any signs she was unwell.
She said Ms Saint George had left the property during a conversation about moving to a mother and baby unit, saying she did not want to go.
Detective Sergeant Ian Valentine told the inquest: “I take no pleasure as a homicide detective that this case has not ended up in court.”
Summing up the inquest, Ms Hassell said: “I have heard evidence that Lily-Mai died as a consequence of a head injury at the time of her death.
“She suffered 19 rib fractures that in addition to this she had an injury to her right leg, deep within the growing structure of the bone and that she also had bleeding around both optic nerves typically associated with a head injury.
“She suffered side to side compression, not associated with rib fractures such as one might sustain from CPR. The injury to her right leg was from forceful traction and twisting. This would have been inappropriate and greatly in excess of rough handling, so I heard.
“The explanations of potential accidental mechanisms of injury from Lily-Mai’s parents were discounted by the forensic pathologist who examined Lily-Mai after death as not consistent with her injuries.
“When she suffered the head injury the effect would have been immediate and very noticeable. In summary she had a head injury, an eye injury, spinal injury, leg injury, rib fractures and many many bruises such as one would definitely not expect in a newborn baby.
“Taking into account the description from the forensic pathologist and that from the pediatrician who gave expert evidence that this was a massive, massive injury I am entirely convinced that Lily-Mai died as a consequence of injuries that were non-accidental.
“Given the force that I have heard would need to have been applied to suffer these injuries, I accept this evidence in its entirety from both Dr Cary and Dr Ehrhardt, I am entirely satisfied that Lily-Mai was unlawfully killed.
“I have heard the evidence from several professionals charged with taking care of Lily-Mai that the doctors and nurses at Barnet Hospital were extremely concerned about her and that they did not believe it was safe for her to be discharged from the care of her parents.
“There were other professionals who were of the same view, and yet Haringey Children’s Services did facilitate that discharge and that is utterly bewildering to me.”