Stoke-on-Trent agency delays before woman killed children
A woman who killed her two children before herself should have had a faster response from agencies after she talked of harming them, a review found.
Marta Galikowska, 27, was found dead with daughters Maja, five, and Olga, one, at Sherwin Road, Stoke-on-Trent.
She had seen mental health workers in the days before their deaths, in October last year.
Stoke-on-Trent's Safeguarding Children Board said it had reviewed how workers relayed information.
An inquest on 9 December heard Mrs Galikowska became depressed after mistakenly believing a lump in her eldest daughter's neck was cancerous, despite reassurance from doctors.
'No urgent referral'
The coroner concluded the girls died from stab wounds and were unlawfully killed by their mother, whose death was recorded as suicide. All three were found dead on 12 October, 2014.
The serious case review reported that on Friday 3 October, 2014 Mrs Galikowska, a Polish national, was seen by a GP with husband Marcin, who made the appointment after becoming concerned about his wife's mental state.
After Mrs Galikowska admitted having thoughts about killing herself and her children, the GP referred her to mental health professionals and told her they should contact her later that day.
The doctor was told "urgent referrals service-users will be contacted within four hours", the review said.
But, neither the GP nor the call taker referred the case to children's social care and as a result professionals did not visit the family until Sunday 5 October.
The serious case review concluded this referral should have been made and the case would then have been "treated correctly" as a child protection investigation.
'Extremely concerning delay'
Further telephone calls were made on 6 October, but after a surprise visit on 7 October the mother's mental health was not judged to have deteriorated and the mental health service announced it was closing the case two days later.
The review criticised the "extremely concerning" delay between the GP's referral and mental health workers visiting the family and described further telephone calls in place of home visits as "poor practice".
"There is a pattern in Stoke-on-Trent of professionals making assumptions about other teams/agencies' roles, responses and remit, which can leave families vulnerable and both professionals and families with false expectations," it said.
However, the review acknowledged "without the benefit of hindsight it is understandable" mental health workers did not believe the children were in immediate danger because of Mrs Galikowska's behaviour and her husband's support at visits.
John Wood, chairman of the Stoke-on-Trent Safeguarding Children Board, said improvements had been made since the Galikowska case, including establishing a 24-hour mental health and social care access team.
"The devastating events united a whole community in grief and have been treated with the utmost seriousness by the city council, the police, health and other public services," he said.