A woman who killed her three children had become "overwhelmed" by their care up to four years before, a report said.
Tania Clarence, of New Malden, south-west London, admitted the manslaughter of her three-year-old twins Max and Ben and daughter Olivia, aged four.
Professionals recognised as early as 2010 that she was probably depressed, the serious case review noted.
Despite making 14 recommendations, the review stated the disabled children's killings in 2014 were not preventable.
All three children had spinal muscular atrophy type 2, a life-shortening condition that causes severe muscle weakness which can result in problems moving, eating, breathing and swallowing.
They were found dead at their home on 22 April after Clarence had smothered them.
'Intelligent and bright'
She pleaded guilty to manslaughter by way of diminished responsibility and was detained under a hospital order in November last year.
The report found that by the end of 2010 she was probably suffering with depression and had been "overwhelmed" by the high number of appointments she had to keep since her twins Ben and Max were born that summer.
Up to 60 professionals are thought to have been involved with the family's case.
Officials said the children enjoyed their lives and described them as "intelligent, bright," and "lively".
Clarence, 43, was observed to have had an affectionate relationship with Olivia, but the premature births of the twins caused a "huge emotional and practical adjustment" for the family in July 2010.
She told health practitioners she never had a full night's sleep because of the children's disturbed sleep patterns and was often found to be tearful and tired when they visited her, but had refused help for her suspected depression.
Mr Clarence said his wife had dedicated her life to loving and caring for the children and always put their wellbeing before her own.
Serious Case Review
At the heart of this case was the tension between supporting the family's needs while also being more assertive about using child protection measures to remove the children from an environment where the primary carer was under immense pressure.
The professionals also had to take into account ethical dilemmas about the children's quality of life, palliative care and the potentially competing parental views.
It has recommended:
- Child-In-Need planning, involving multiple agencies, needs to be led by a social worker and not a health worker
- Parents should routinely be offered counselling and support information whenever a child is diagnosed with a disability
- Health practitioners should explore parents' cultural background and their attitudes towards council services
- A system to ensure all case workers feel able to escalate concerns
- A clear system to flag up child protection referrals and ensure referral recommendations do not get lost when information is shared by different agencies
The parents indicated they did not want invasive medical intervention that might cause their children pain and had signed a "do not resuscitate order" for ongoing treatment, because they prioritised quality of life over life-lengthening treatment, the report said.
Professionals had reported concerns Clarence did not always follow their advice and a discussion was raised about whether the child protection threshold had been reached in this case, "but this was never agreed", the report found.
Two local authorities and two hospitals explored the possibility of legal intervention in the case but an apparent breakthrough was made in April 2014 when their father Gary agreed to allow Olivia to have a stomach operation.
He was also seriously considering spinal surgery too, which though painful might have provided some benefits.
The report said it was not known whether the mother had consented to the operations because the pair had requested that all discussions about medical intervention be discussed with the father.
Clarence killed the children soon after she was left alone with them in April, when her husband went to visit his relatives in South Africa.
- 18 November 2014
- 18 November 2014
- 14 November 2014