A report into the murder of a newborn baby in 2007 in Aberdeen has found that NHS staff could not have prevented her death.
Mark Simpson was found guilty of murdering his girlfriend's six-week-old baby Alexis Matheson in 2010. Judge Uist sentenced him to life and he will serve a minimum of 20 years.
Simpson assaulted baby Alexis at his home in Aberdeen while the little girl and her mother Ilona Sheach were living there.
Lord Uist branded Simpson a "devious and deceitful" individual.
The judge added that he believed the health service had let Alexis down and that a fatal accident inquiry into the death should go ahead.
However, a report by the North East of Scotland Child Protection Committee (NESCPC) has found no evidence of staffing difficulties within the midwifery, health visiting or GP services and that the actions taken by the health visitors were persistent and professional.
The report by Judge Howard Llewellyn, on behalf of the NESCPC, stated: “I conclude that her death was not predictable from the information available to practitioners.
“I conclude that although her injuries may have been treatable in the few days before her death, her survival was possible rather than probable. I do not therefore conclude that her death would have been prevented.”
The report revealed that Judge Llewellyn did not meet Alexis’s family as they declined to take part in the review. He was also unable to interview the doctor who was the "only GP who actually saw Alexis before her death", but did not examine her.
He said the case was “very unusual” as it covered a “very short period i.e. six to seven weeks” from Alexis’ birth.
“I found no evidence to indicate that there were any significant or mounting concerns being expressed by anyone either over Mark Simpson’s involvement with Alexis; as to [the mother’s] parenting abilities or as to Alexis’s health,” he said.
“Although [the mother] demonstrated some resistance to engagement with the routine contacts available to new mothers the evidence shows that those responsible for facilitating that engagement, i.e. the midwives and health visitors, sustained a pro-active approach to contact with her even when she failed to attend appointments.
The judge made eight recommendations including that “when a young child, especially a newborn, is presented for a consultation GPs should always consider conducting a physical examination. They should record any such examination which follows. If they decide not to conduct an examination they should record their reasons for not doing so”.
He also recommended that telephone appointment systems should allow for the identification of babies and offer an appointment within 24 hours and that the practice of GPs prescribing drugs by telephone for babies should be reviewed.
Elinor Smith, director of nursing for NHS Grampian, said: “This is an important report. It attempts to constructively identify institutional weaknesses and so is more helpful in learning lessons for future practice than concentrating on fault finding.
“I welcome Mr Llewellyn’s conclusion that all professional NHS staff were committed to delivering the best service and that the midwives and health visitors sustained a proactive approach to maintaining contact with mum and baby.”
“NHS Grampian has already actioned many of the recommendations but others require more detailed planning over a longer period.”
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