Joshua Millinson murder: How tragic Wolverhampton newborn was let down
Defenceless Joshua Millinson was shaken to death by his father in the living room of their home.
Daniel Sanzone is serving a life sentence for his murder. He will serve at least 15 years behind bars.
A serious case review, published today, revealed that several agencies including Wolverhampton council and the National Probation Service had contact with either Joshua's mother, Zoe Howell, or 23-year-old Sanzone in the months before Joshua was born.
But there was failure to co-ordinate their work and share information stemming in part from the fact Sanzone was not identified as the newborn's father until after the fatal attack.
The report states a pre-birth assessment of Miss Howell was carried out by a social worker on May 12, 2015.
This arose from concerns about how she behaved during appointments with midwives and also risks that might arise from contact with a sex offender who it was believed had contact with the family.
But during the visit a view was formed Miss Howell had a good network of family support, stable housing and was in receipt of the right state benefits.
Wolverhampton Safeguarding Children Board (WSCB), which published the serious case review, found it had been a 'weak' assessment.
The report states: "It did not explicitly address a number of the concerns identified in the original referral and central referral team management decision (such as the concerns about the mother's behaviour with other professionals)."
In relation to the sex offender the family had contact with, the report said: "The assessment accepted that the convicted offender no longer posed a risk, because the grandmother said that he was dead, but there is no evidence that this was checked or that the information was shared with other agencies.
"There were only limited attempts to identify the father. This should have been given more priority given the potential vulnerability of the mother."
The National Probation Service was responsible for supervising Sanzone between May and October 2015 following a conviction for burglary.
He told staff about an allegation of sexual assault against a young child and later revealed his girlfriend was pregnant.
Again the safeguarding board found there were missed opportunities to make the connection between mother and father. The report states: "No steps were taken to evaluate whether there might be safeguarding concerns for the unborn baby or other children that he had contact with.
"Probation service contact was exclusively with the father. This was part of a pattern whereby agencies worked exclusively with one partner."
Responding to the findings, a spokesperson for the National Probation Service, said: "Public protection is our priority. A full review was undertaken and all identified learning was taken forward.
"We will also carefully consider the findings of the serious case review."
The report also highlights 'shortcomings' in the arrangements for safeguarding children at New Cross Hospital's A&E department which Joshua attended twice before he was murdered. It says there were 'variations' in safeguarding training and in the level of experience of the staff who saw Joshua.
It states in the report: "All of the staff who had seen Child F conveyed clearly to the review that they were mindful of possible safeguarding concerns when they saw him.
"However this general awareness was not always matched by detailed interrogation of possible risk factors which was in turn not supported by the hospital's systems.
"Staff were overly reassured by the fact that the clinical examination found no evidence of pain or injury and insufficiently aware that an injury in such a very small child might be asymptomatic."
The report does however make clear that a bone fracture which may have existed at that time was 'very unlikely' to have been identifiable.
It was recommended by the safeguarding board that the Royal Wolverhampton NHS Trust should undertake a review of the safeguarding arrangements in A&E at New Cross Hospital.
Joshua suffered his fatal injuries on October 24, 2015.
It would later emerge that Sanzone had vigorously shaken Joshua while alone with him in the living room.
It was decided that Joshua's brain injury was so severe and life support was withdrawn on November 20.
He died the next day.
Miss Howell was cleared of any wrongdoing.
