THE murder of a five-year-old girl probably would have been prevented if doctors, police, social workers and the courts had pooled more information about her father.

A serious case review into the death of Gabby Grady, who was deliberately driven into the icy river Avon at Evesham by her father Chris Grady in February 2010, found several agencies could have done more to protect her and her brother Ryan, who survived the tragedy.

Mr Grady, currently serving a life sentence for the murder of Gabby and the attempted murder of Ryan – then aged six – was on several agencies’ radars and threatened to kill his children and himself in November 2009, but intervention into his behaviour came too late to stop him carrying out his threat.

The case review carried out by the Worcestershire Safeguarding Children Board (WSCB), looking at which agencies had dealt with the children and how they had worked together in the run-up to Gabby’s death.

The report says: “If the agencies had shared information [at certain key points] and had undertaken an assessment of father’s state of mind and the risk he posed to the children, it is likely the event leading to the death of BW [Gabby] and the near death of CW [Ryan] could have been prevented.”

However, it does acknowledge Grady may have driven his children into the river “whatever intervention had been made at the time, if father was determined and committed to this course of action”.

A serious case review was triggered after it emerged Grady had a history of mental illness, fully documented in the report.

The review’s purpose was to set out what lessons can be learned to stop a repeat of the tragedy, but does not apportion blame.

The report found throughout that where one agency had information, through a referral or a call-out, or appointment, the details were sometimes not shared with others and where it was, the information was sometimes not acted upon.

For example, although both parents went to the same GP practice for treatment over anxiety and depression and for Mr Grady’s drink problem, these details were never flagged to Worcestershire County Council’s children’s services as a potential concern over the children’s welfare.

The police were repeatedly called to domestic rows, often centred on custody arrangements, and children’s services were told but did not “make any direct contact” with the children, instead sending letters to the parents.

Between October 2008 and September 2009, the Children and Family Court Advisory and Support Service (Cafcass) was involved over the children’s custody arrangements ahead of a court hearing.

But the report notes Cafcass, the GPs, the police or children’s services “did not collaborate and pool their information”.

The findings charted a “gradual” breakdown in the relationship between the parents eventually ending in autumn 2009, although there was no evidence of any physical violence against the children.

It said the children were “children whose needs were not assessed at different points in time when their welfare should have been promoted as ‘vulnerable children in need of services and of safeguarding’”.

It said the children were not spoken to alone – to assess how they were thinking and feeling without their parents being present – until February 2009 when the parents’ relationship had already been in turmoil for a year.

When Grady threatened to kill himself and the children in November 2009 the children were not seen by children’s services until December and then, again, not on their own.

The report also highlighted that a key assessment meeting scheduled with the children had still not taken place 53 days after the original referral – by which time Grady carried out his threat, driving his children into the river.

Grady managed to swim free of the car, and Ryan was rescued, but his daughter Gabby was trapped for two hours under water.

At a trial earlier this year, he was sentenced to life in prison and must serve at least 15 years in jail for murdering his daughter with a 10-year sentence for attempted murder of Ryan.

Hilary Thompson, WSCB chairman, said: “This was a devastating event for the family including for a surviving child.

“It is important we learn from this case in order to better equip professionals to intervene and protect children where is possible.

“It is possible the events would have happened whatever intervention had been made at the time if the father was in a state of mind where he was determined and committed to the course of action.”

She said the agencies involved had all made recommendations for improvement, which had since been acted upon as had the inter-agency recommendations set out in the report.

“The recommendations focus on tighter procedures, better training, early and robust information sharing and better engagement of some key professionals in the child protection system,” she said.

She said both parents were consulted throughout the review and the findings had been shared with them.

Five points where information should have been shared

The serious case review identified “five crucial points” where information should have been shared:

One: All agencies failed to access all the information about the children’s circumstances amid the break-down of their parents’ relationship when Children and Family Court Advisory and Support Service (Cafcass) first became involved.

Two: Worcestershire County Council Children’s Services sent letters to both parents following reports of domestic violence by Kim Smith, and allegations about the care of the children by Chris Grady, but failed to follow-up the needs of the children.

Three: In August 2009, children’s services and the police failed to speak with the children after a call-out to an incident, and should have told Cafcass.

Four: Cafcass should have checked that Grady’s allegation about Miss Smith’s care of the children was responded to by contacting children’s services.

Five: After Grady threatened to kill himself and the children in November 2009, checks should have been made with health agencies, schools, and others.

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