The death of a six-week-old baby who was killed after being repeatedly assaulted by her mother's boyfriend could not have been predicted, a report has concluded.
Alexis Matheson died after a series of attacks by Mark Simpson at the home he shared with the baby's mother in Aberdeen.
She died in hospital in Edinburgh on December 10, 2007, with Simpson found guilty of the baby's murder and sentenced to life in jail with a minimum tariff of 20 years.
Judge Howard Llewellyn chaired a significant case review to consider whether the baby's death could have been prevented had signs of non-accidental injury been detected earlier.
"I conclude that her death was not predictable from the information available to practitioners," he said.
While he concluded Alexis's injuries may have been treatable in the few days before her death, he said: "Her survival was possible rather than probable. I do not therefore conclude that her death would have been prevented."
The review took place after Lord Uist, the judge during Simpson's trial, said some of the evidence gave him serious concern about how the health service dealt with Alexis's case.
The court had heard that baby's mother, Ilona Sheach, sought a doctor's appointment because she was seriously worried about her baby's health, but was only offered one for the following week. Alexis was seen by a doctor on November 29, 2007, but nothing was done about possible signs of non-accidental injury, the court had heard.
Mr Llewellyn concluded NHS staff were "committed and hard-working professionals who aim to deliver the best service they can to the public".
He added there was "no evidence to indicate there were significant or mounting concerns being expressed by anyone" over Alexis's health or Simpson's involvement with the baby.
Mr Llewellyn said he found no evidence of significant staffing difficulties within the midwife service, the health visiting service or the GP practice at which Alexis was seen.
However, he recommended the telephone appointment system operated by GPs be reviewed so that in future it can be determined if the patient is a baby – and if so, an appointment within 24 hours given.
The practice of prescribing drugs over the telephone for newborns should also be reviewed, he said, because a GP's ability to diagnose infants' needs is "inherently inhibited" by not being able to see them.
Doctors should always consider physically examining young children and if they decide not to do this, they should record their reasons, the judge recommended, and the training of GPs and health visitors should be reviewed to ensure they can recognise the signs of non-accidental injury.
NHS Grampian has already introduced changes in the wake of Alexis's death.
Communication between health visitors and GPs has been improved and they have been provided with better child protection training.
Elinor Smith, director of nursing at the health board, said: "This is an important report. It attempts to constructively identify institutional weaknesses and so is more helpful in learning lessons for future practice than concentrating on fault finding. I welcome Mr Llewellyn's conclusion that all professional NHS staff were committed to delivering the best service and that the midwives and health visitors sustained a proactive approach to maintaining contact with mum and baby.
"NHS Grampian has already actioned many of the recommendations, but others require more detailed planning over a longer period.
"The improvements being made will benefit children in the future."
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