There were missed opportunities to protect a baby girl who was murdered by her father two weeks after he formally adopted her, a review has found.
Matthew Scully-Hicks, 32, passed the rigorous adoption process with flying colours and professionals viewed his care of 18-month-old Elsie Scully-Hicks through a "positive lens".
The fitness instructor, who had previously adopted another child, violently shook Elsie and threw her to the floor at their home in Llandaff, Cardiff, on May 25 2016.
In the months before that fatal attack, Scully-Hicks had inflicted a catalogue of injuries on Elsie, including a large bruise to her forehead and her leg being fractured in two places.
An extended child practice review found professionals saw Elsie's injuries in isolation, lacked "professional curiosity" and accepted what Scully-Hicks told them.
Scully-Hicks, of Delabole, Cornwall, was jailed for life and ordered to serve a minimum of 18 years after being convicted of murder following a trial at Cardiff Crown Court last year.
At a press conference in Cardiff on Thursday, Lance Carver - the director of social services at Vale of Glamorgan Council - apologised for errors in Elsie's case.
"The findings do indicate that social workers and staff from all agencies saw the adoption as very positive," Mr Carver said.
"They perceived the adoptive family as a really positive solution for Elsie.
"The report identifies issues that 'that positive lens' meant that they were not looking in the way they should have been.
"That's something as an organisation that we should have recognised and taken that fully on board."
Mr Carver said no disciplinary actions had been taken against any members of staff as the report did not "indicate that it would be appropriate".
Elsie, named Shayla O'Brien by her birth family, was born in November 2014 and was taken into care five days later.
The bright and alert baby was placed with Scully-Hicks and his husband, Craig, in September 2015, when she was aged 10 months.
Two months later, she was referred to an orthopaedic outpatient clinic by her GP after suffering an injury to her leg, which had not been weight-bearing for five days.
A registrar examined her X-ray and identified a fracture to Elsie's lower leg but failed to spot another one to her upper leg.
"Had both fractures been recognised on the x-ray this would have raised safeguarding concerns that would have instigated the child protection process," the report states.
Sarah McGill, of Cardiff and Vale Safeguarding Children Board, apologised on behalf of all agencies involved with Elsie for the missed opportunities in her case.
When asked whether Elsie's death could have been prevented, she said: "I think that is a very, very difficult question to answer.
"When you look back at the pattern of injuries, particularly between the period of November 2015 and March 2016, you can see that had there been one agency or one worker that had all of that information, potentially there would have been an opportunity to raise safeguarding concerns."
In December 2015, Elsie suffered a large bruise to her forehead, which lasted for eight weeks.
Two social workers and an independent reviewing officer, from Vale of Glamorgan Council, saw the bruise - described as "a real shiner" - but did not make any reference to it in their notes.
Days later, a health visitor also spotted the bruise and advised Scully-Hicks to seek medical attention. He lied and said he had already done so.
"The observations and recording of the large bruise to the child's forehead both by children's services and health was absent," the report states.
"This resulted in the large bruise becoming 'invisible' to professionals and did not form part of the building an overall picture of what was happening to the child before the final report to the court prior to the adoption order hearing being made."
Elsie suffered a further bruise to her forehead in January 2016, which Scully-Hicks gave no explanation for.
In March 2016, an ambulance was called to the family home after Elsie apparently fell down the stairs. She was taken to hospital but allowed to return home four hours later.
"The significance of the injuries that the child sustained were minimised to be compliant with the professional's view that the child was an active toddler and receiving good care," the report states.
"The explanations provided by the parents were considered by health professionals as being consistent with accidental injury."
High Court judge Mr Justice Moor later ruled that Scully-Hicks had shaken Elsie on three occasions - when she broke her leg, when he claimed she fell down the stairs and when she suffered fatal injuries.
The judge described Scully-Hicks, who referred to Elsie as "Satan dressed up in a babygrow" in text messages, as a "Jekyll and Hyde" character.
All of Elsie's injuries took place when she was alone with Scully-Hicks, who was known to be "under stress" caring for the little girl and her adoptive sibling, the report said.
His husband was frequently working away from home in his role as a company director.
The family court, which approved Elsie's adoption on May 12 2016, was also not aware of concerns that she was developing a squint.
On May 25, Scully-Hicks called emergency services to the family home claiming that he had found Elsie unresponsive.
She died in hospital four days later. Her birth family was not informed of this until January 2017.
The report, which was published on Thursday, made nine recommendations.
ELSIE SCULLY-HICKS DEATH: HOW EVENTS UNFOLDED
The following is a timeline of events relating to the death of Elsie Scully-Hicks.
- 2006 Matthew and Craig Scully-Hicks meet - the latter owns a nightclub in Swindon.
- 2008 The pair start a relationship.
- 2012 August 10 - They marry in Portugal, having moved to Wellwright Road, Cardiff, the previous year.
- November 17 - Elsie is born and taken into care a few days later.
- November 24 - Matthew and Craig Scully-Hicks register interest in becoming adopters.
- January 9 - Initial visit by adoption manager Bethan James regarding adoption.
- January 28 - Matthew and Craig Scully-Hicks attend adopter training.
- February 20 - Initial visit by Laura Neal, social worker, with the couple for assessment as potential adopters.
- March 9, 20 and 30 - Further visits by Ms Neal to assess the Scully-Hicks.
- April 9 - Application for adoption received by local authority.
- April 13 - Further assessment visit by Ms Neal.
- April 13 - Disclosure and barring service (DBS) check received for Matthew Scully-Hicks.
- April 17 - Matthew and Craig Scully-Hicks pass medical examinations.
- April 23 - Care and Social Services Inspectorate Wales check received.
- April 27 - Local authority check received.
- April 28 - DBS check for Craig Scully-Hicks received.
- May 1 - NSPCC check for couple received.
- June 12 - Review assessment of Matthew and Craig Scully-Hicks as prospective adopters with Ms Neal and Ms James.
- July 17 - The Scully-Hicks are presented to the Vale of Glamorgan adoption panel as prospective adopters and approved.
- July 22 - Decision for them to adopt ratified.
- July 30 - Ms Neal and Mark Lloyd-Selby, Elsie's social worker, visit the Scully-Hicks.
- August 11 - The couple attend an appointment to discuss Elsie's medical needs with Ms Neal.
- August 17 - Matthew Scully-Hicks meets Elsie's foster carer to discuss her personality, routine and care needs, with Ms Neal.
- August 21 - Match presented to the adoption panel.
- September 1 - Match is ratified.
- September 3 - Adoption introductions between the couple and Elsie begin.
- September 9 - Review of adoption introductions chaired by Vale, Valleys and Cardiff adoption manager Elizabeth Dickinson. Decision is taken to place Elsie with the couple the next day.
- September 10 - Elsie is placed with Matthew and Craig Scully-Hicks.
- September 17 and 28 - Elsie observed during social work visits to the Scully-Hicks' home by Hillary Southam and Ms Neal.
- September 21 - Matthew Scully-Hicks sends a message referring to Elsie having "a proper diva strop".
- September 22 - He sends further messages about Elsie screaming, having "a diva strop", and being "a psycho".
- September 29 - Adoption review at the house with social workers and independent reviewing officer Erol Bowers.
- September 29 - Scully-Hicks describes Elsie as "Satan dressed up in a babygro" in a message to his husband.
- October 21 - Health visitor Jodie Golten visits and observes Elsie.
- November 5 - Elsie suffers a leg injury while in the care of Matthew Scully-Hicks.
- November 9 - Elsie is seen by a GP and referred to the orthopaedic outpatient clinic.
- November 12 - An X-ray shows Elsie has fractured her leg, above her right ankle.
- December 1 - Elsie attends clinic with health visitor Ms Golten.
- December 2 - Visit by social worker Cheryl Longley.
- December 3 - Elsie's cast is removed.
- December 16 - Elsie suffers a bruise to her head, by her left eye. Matthew Scully-Hicks sends a text message to a social worker reporting a large bruise to Elsie's forehead.
- December 17 - Adoption review with Ms Neal, Erol Bowers and Ms Longley. They do not record the presence of the bruise in their notes of the meeting.
- December 21 - Health visitor Ms Golten visits and advises Matthew Scully-Hicks to get Elsie's bruise checked out if he had not already. She later says he told her he had, but the court hears no evidence could be found of him doing so.
- January 18 - Elsie suffers another bruise to her head.
- January 26 - Social worker visit with Ms Longley.
- February 23 - Matthew Scully-Hicks and Elsie attend adoption medical.
- February 26 - Social worker visit with Ms Longley.
- March 10 - Elsie is taken to hospital after falling down the stairs.
- March 14 - Social worker visit with Ms Longley.
- April 16 - The Scully-Hicks move house to Llandaff, Cardiff.
- April 22 - Adoption review at the new address.
- April 26 - Elsie appears to have developed a squint and sees a GP.
- April 29 - Social worker visit by Ms Neal.
- May 3 - Elsie is seen by a GP.
- May 6 - Elsie attends the children's clinic at St David's Hospital and sees a consultant neonatologist.
- May 12 - Elsie is formally adopted by Matthew and Craig Scully-Hicks.
- May 25:
- 6.18pm - Matthew Scully-Hicks calls 999 reporting Elsie is unresponsive.
- 6.26pm - Police and paramedics arrive at the family home.
- 6.53pm - Elsie arrives at the University Hospital of Wales.
- 7.30pm - Craig Scully-Hicks arrives at the hospital.
- May 26 - Elsie's condition deteriorates.
- May 28 - Elsie's family are informed that she is unlikely to survive the night.
- May 29 - Elsie's ventilator is turned off and she dies at 2.05am.
- June 27 - Matthew Scully-Hicks is interviewed by police.
- December 21 - Matthew Scully-Hicks is arrested on suspicion of Elsie's murder.
- - 2017
- October 9 - Matthew Scully-Hicks goes on trial at Cardiff Crown Court.
- November 6 - He is convicted of murder.
- November 7 - He is jailed for life with a minimum term of 18 years.
- - 2018
- August 2 - An independent inquiry finds there were missed opportunities in the care of Elsie.
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