Taplow train deaths: Council hits back over social worker criticism

Leighane Melsadie Redmond and her daughter Melsadie Adella-Rae Parris both died of multiple injuries on February 18, 2019.

A coroner sitting in Beaconsfield ruled that Ms Redmond, 27, was likely to have been “legally insane” at the time she and her daughter were hit by a train.

However, assistant Coroner Ian Wade KC had also issued a Prevention of Future Deaths Report (PFD) where he criticised social workers employed by the council, stating they had not followed best practice.

Staff at Children’s Services had been informed on January 9, 2019 by Melsadie’s father, Leroy Parris and her grandmother, Yvette Redmond, that Ms Redmond had described her daughter as “evil”.

Despite this information coming to light, the social work staff had made the decision to close the case into Melsadie and her mother.

Mr Wade, in his PFD, said: “The team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. 

“The team did not conduct a renewed visit to the home, nor seek up to date information from the family, nor liaise with the mental health team. 

“It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis.

“It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer.”

The coroner added that Buckinghamshire Council’s existing guidance and policy were “dynamic processes requiring rigorous scrutiny” but said the staff had failed to adhere to this “good practice”.

Responding to the coroner, the Corporate Director of Children’s Services said the council was “pleased to note” that the existing policies and guidance were sufficiently robust and said as a result the council did not propose to re-visit them.

The director also accepted “the Assistant Coroner’s view that best practice in employing those policies was not followed”.

However, the Director hit back at some of the criticism levelled at the social work staff, adding: “We do consider it important to note for the purposes of our response to the PFD, that in this particular case, the Local Authority consider that the legal test (Threshold) for any further statutory intervention was no longer evidenced and that this is what prompted the closure decision. 

“It is respectfully noted at this juncture that the Assistant Coroner himself confirmed within his Findings that ‘Melsadie was not a child in need and was not at risk. In January 2019 Melsadie was well cared for. She was loved. Her mother was in good jobs.

"Her mother was taking appropriate steps to deal with her debts. Her mother was interacting with doctors, employers, a landlord, her neighbours, her ex-partner, her friends, her child’s nursery, the child social work team…in ways which were reasonable, appropriate, reassuring – even impressive. She was in fact interacting with her mother’.

“Finally, we would also take the opportunity to respectfully note that in the event that a manager instructs a further visit to take place in the future and either a) the family do not make themselves available to the social worker or b) refuse such a visit, in the absence of any other new evidence identifying a current safeguarding concern, the threshold to insist upon a further visit will not be met and the case will close in any event as the Local Authority would then have no legal right to be able to investigate any further.”

Despite this, the Director said that going forward, staff will be required to properly evidence the rationale and decision-making process that informs their professional judgment resulting in the closure of cases.

The Director concluded: “Buckinghamshire Children’s Social Care are determined to learn from this deeply tragic case and do take the Coroner’s concerns very seriously.”