Kristal Davison death: Agencies 'missed chances' to protect baby
A review into a seven-week-old baby's death has found opportunities were missed to share her father's history of domestic violence between agencies.
Kristal Davison died in April last year from a head injury after at least two "episodes of violence or trauma".
Her father Lee Davison, 28, was jailed for eight years at Leeds Crown Court in July.
The Wakefield Safeguarding Children Board review said information-sharing "fell below expected standards".
The review concluded that the only way Kristal's death could have been prevented was if she had been removed from her parents, but care workers had not been made aware of his criminal history.
It reported that the 28-year-old had a learning difficulty and previous convictions for violence, theft and damage.
It stated that if all the information had been "collated and understood more adequately, it is highly probable that Kristal would have been subject of formal child protection inquiries".
"Contact with her father would have been managed differently," it said.'Ask more questions'
Lee Davison called an ambulance on the morning of 12 April 2012, reporting that Kristal was gasping for breath.
End Quote Edwina Harrison Chairwoman, Wakefield Safeguarding Children Board
It is not enough just to recognise that more could have been done”
When paramedics arrived, she was found to be pale, limp and lifeless and was taken to hospital, where she died the next day.
Kristal had been seen by a number of health professionals, including a health visitor and a doctor, two days before her death but her injuries were not found.
Davison was jailed for allowing or causing the death of a child.
Kristal's mother Jessica Hopkinson, 19, from Pontefract, was acquitted of the same charge.
The review highlighted the reporting of domestic incidents where Kristal's mother had been assaulted by Lee Davison.
"The maternal grandfather reported concerns about the behaviour of Kristal's father to three different services - the police, the safeguarding and family support service and the health visiting service," it said.
"None of these reports achieved a significant response.
"Some of this probably reflected the fact that, in general, [the child's] father was seen as being positive and compliant, rather than controlling.
"More significantly, it also reflected an absence of information about his history with previous partners."'Highlighted a need'
The Wakefield and District Safeguarding Children Board document said that "police held information that would have been relevant to professionals working across agencies".
However, it stated that there was "no corresponding record of inquiries" being made of the Wakefield Safeguarding and Family Support Service by West Yorkshire Police.
The board's chairwoman Edwina Harrison said it was "not enough just to recognise that more could have been done".
"We owe it to the family to make sure that professionals have the ability and confidence to ask more questions, raise concerns and have all the relevant information they need to make what we know are very difficult and complex decisions."
A West Yorkshire Police spokesman said the review had "highlighted a need" for the force to "reiterate to all staff within safeguarding units of the circumstances in which a child protection referral will be made to social care concerning police attendance at domestic abuse incidents."
"This has been done and we will continue our efforts to ensure that appropriate referrals are made."