Long read: How opportunities were missed to save Ilford baby who died at hands of unqualified Barking babysitter
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Opportunities were missed to protect a vulnerable 11-month-old baby from Ilford who died in the care of an unqualified Vietnamese babysitter in Barking, a review has found.
A serious case review, carried out by Redbridge Local Safeguarding Children Board, paints a graphic and detailed picture of the experiences of Huong Nguyen, a Vietnamese asylum seeker, and her daughter Tina Nguyen, who both lived in Ilford, before she died in the care of an unqualified babysitter in Barking on October 5, 2017.
The report finds that the Home Office lost sight of Tina and Huong for 10 of the 11 months of the baby's life, and was not able to fully meet its statutory obligation to safeguard and promote the welfare of children in the UK.
The review makes 19 recommendations to the Home Office, individual agencies and the newly established Safeguarding Partnership in Barking and Dagenham, Havering and Redbridge to improve the asylum system.
The board expressed its heartfelt condolences to Tina's mother for her devastating loss.
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"No blame attaches to her for her baby's death," the report says.
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Huong Nguyen fell pregnant soon after arriving in the UK on a lorry in October, 2015.
But the Home Office considered her situation to be stable when she first arrived.
She was living in a flat in Hackney with the baby's father and it was established that the father was a UK citizen, who was supporting the mother financially at the time.
She did not make any claim for financial support at this time and the Home Office did not believe that she had been or was being exploited in any way.
When the circumstances changed and the father left, the Home Office arranged emergency accommodation and longer-term support.
But then the Home Office lost sight of mother and baby.
They wrote to her on December 7, 2016, to advise that they had been unable to make a decision on her asylum claim and would review her case in three months.
The review never took place and the Home Office had no contact until it was notified of the baby's death in October 2017.
The Home Office said it was experiencing resource issues at the time as a result of a high turnover of staff and it was struggling with a high number of "non-straightforward cases".
What happened when Tina was born
Tina was born on November 7, 2016, at Croydon University Hospital.
She was described as a "happy and contented child" who was alert and attentive.
"She regularly smiled when she was given attention," the report says.
But Huong and Tina were moved to four different homes in Tina's short life, which meant the family could never settle.
They spent three months in Hackney, two months in Croydon and one month in Cardiff, before being placed in permanent accommodation in Ilford.
Huong and Tina were moved to Cardiff when the baby was just one-month-old, a move which was deemed to be temporary but saw them stay in two separate places in the Welsh capital.
Huong said she shared a room with other people but felt very lonely because nobody supported her.
Moving Tina and Huong to Cardiff exposed them to risk and increased their vulnerability, the report says, and moving her twice during her short stay in the city was "completely inappropriate".
"The brevity of the stays also put pressure on agencies to work quite rapidly with the family whilst limiting the depth and intensity of the work is was possible to accomplish," the report says.
Baby and mother arrive in Ilford
The baby and her mother were moved to an eight-bedroom house in Ilford on January 18, 2017, for mothers and their children, run by Clearsprings, a company that provides housing for asylum seekers.
There were four mothers and their children living there, and one of the other asylum seeker mothers was also Vietnamese.
Once she arrived in Ilford, the mother said a health visitor offered her support but due to the language barrier, she was unable to understand the mother and therefore was not in a position to do anything to help her.
The mother was helped by Redbridge Foodbank and the Salvation Army, which provided food and clothes for her and the baby.
But she was critical of Ilford Medical Centre.
She said she took the baby to see the GP quite often and saw many different GPs who were often unable to help her because of the absence of interpreters. It was also claimed that reception staff laughed at her on one occasion.
However, the medical centre suggested it would be out of character for admin staff to laugh as they are trained to deal with patients who cannot speak English.
Huong also praised the mental health services provided to her in Redbridge.
Mental health issues
In July, the mother visited Ilford Medical Centre as the baby had been coughing a lot.
She told the doctor about her difficulties sleeping and her nightmares where someone was chasing her, adding that she had postnatal depression and was having suicidal thoughts.
She also said she hadn't heard from the Home Office in a year and didn't think her lawyer was actively seeking an update on her claim for asylum.
The GP made an incorrect assumption that the mother and baby were already known to children's social care and decided not to refer them to children's services, the report says.
An assessment of her mental health a few days later confirmed that she was suffering from postnatal depression.
She may have also been experiencing separation and loss from leaving her two older children and parents in Vietnam.
She was prescribed Mirtazapine, an antidepressant, but her risk was assessed as low.
A therapist said she seemed to be suffering from trauma-like symptoms and she was very isolated as she spoke no English, but she was soon discharged from therapy as the service could only find a male interpreter, who she didn't like.
Problems with interpreters
Of the nine meetings between agencies and Huong, interpreters were available for only five of them.
There were several occasions when Huong's interpreting needs were not met, leading to "less than satisfactory outcomes".
The absence of an interpreter prevented the Redbridge health visitor from gaining a full understanding of Tina and Huong's needs, the report says.
On one occasion, a Mandarin interpreter was booked by mistake which meant the Croydon health visitor couldn't complete a new birth visit after Tina was born.
Huong said the interpreting services were very good in Croydon and Hackey, but not good in Redbridge.
She said her support "disappeared" in Redbridge.
She said that when she arrived in Ilford, she and her baby received support for a time, but then it had ended without notice or explanation.
Overall there was a "lack of professional curiosity" about her and Tina's situation.
Driven to working illegally
In September, Huong started working illegally in a nail bar as a nail technician.
Asylum seekers recieve £37.75 each week and an additional £5 for a baby under the age of one.
Huong's decision to leave Tina with a babysitter appears to have been motivated by a desire to improve her financial circumstances, the report says.
"Arguably, poverty drove mother to work illegally which necessitated leaving Tina in the care of an unregistered childminder, also working in the illicit economy," the report says.
Huong began leaving her baby with Anh Pham, an unregistered nanny, in Barking from 9.15am until 7pm on three or four days each week, for £30 per day.
Pham had advertised her nanny services on a Vietnamese community page and the mother was her first client.
They did not know each other before Pham started looking after her baby.
The day Tina died
The day before Tina died, Pham said the child had needed to be held "all the time", had been unwell and she was a challenge to look after.
Pham care for Tina for 11 days in total and on the day she died, Tina was described by Pham as "being out of sorts", not properly taking her food and vomiting twice.
Pham shook Tina hard and threw her due to her "mounting frustration".
In desperation, Pham knocked on a neighbour's door pleading for help.
An ambulance was called as Tina became very unwell and started having seizures.
Paramedics took her to Queen's Hospital in Romford before she was transferred to Great Ormond Street where doctors battled to save her.
She died later that day.
The head injury was considered unexplained and Tina's case was allocated to the Child Protection and Assessment Team.
The next day, on October 6, police contacted the Home Office to ask about the status of mother and baby.
The Home Office said it had no contact with mother or baby since her placement in Ilford on January 18.
Anh Pham, of Sutton Road, Barking, was convicted of manslaughter and sentenced to six years in prison with a recommendation she serve three on August 12 last year.
She will also be subject to a deportation order on her release. She was ordered to pay a £170 victim surcharge.
Pham came to the UK in 2013 and began working illegally in a nail bar. She was also running her own catering business at the time Tina died.
Pham had a baby in 2015 and applied to the Home Office for leave to remain in March the following year.
Concerns about trafficking
Huong said that when she arrived in the UK, she was taken to a family by the person she travelled with and helped them with tidying the house, cooking, taking care of children and after a period of time, she befriended Tina's father and he arranged accommodation for her.
Concerns about exploitation arose when Tina was admitted to hospital the day she died.
Two Vietnamese men were with Huong at the hospital and initially declined to say who they were.
It is not known if Huong was in debt to anyone involved in helping her travel from Vietnam to the UK, although she disclosed that her parents had paid bribes to secure her release from prison.
What went wrong
The review details many examples where agencies that came into contact with Huong and Tina made considerable efforts to help and support her, in ways that were, "resourceful, caring and kind".
But it also identifies a pattern in which agencies would touch their lives for a brief period, but were unable to sustain ongoing involvement in a way that fully met Huong's needs for support and fully took account of Tina's potential vulnerability.
The deterioration in the mother's mental health had the potential to expose the baby to harm which may have merited a child safeguarding referral by the Home Office, the report says.
When she first arrived in the UK, Huong was considered vulnerable, so it followed that her unborn baby could also be vulnerable.
However, no signposting to services or referral appears to have been considered by the Home Office at the time Huong initiated her asylum claim.
There was also a lack of sharing of information between GP services and inadequate oversight of Huong's case.
What can be improved to make sure it doesn't happen again
The report makes 19 recommendations to the Home Office, individual agencies, and to the newly established Safeguarding Partnership in Barking and Dagenham, Havering and Redbridge.
The report recommends that the government introduce legislation, which would require the Home Office to inform a local authority of the details of any child placed or dispersed to their area, with an asylum seeker parent or parents.
Currently, highly vulnerable children can be placed by a public agency in a particular area and there is no guarantee that the agency with the lead responsibility for safeguarding and promoting the welfare of children - local authority children's social care services - will even know of their existence.
The report recommends that the Home Office takes proactive steps to make sure pregnant asylum seekers and asylum seekers with young children are referred to primary care services at the first point of contact.
It asks the Home Office to consider getting rid of temporary "dispersals" of asylum seeking mothers and very young children, and recommends that they should never be moved before the child is eight weeks old.
Other recommendations include improving the availability of effective interpreting services across Barking and Dagenham, Havering and Redbridge and making sure advice to parents on crying and sleepless babies is accessible in all languages.
John Goldup, independent chair of the safeguarding board, said: "The review does not purport to offer solutions to the huge challenges of the asylum system, but it does recommend some improvements as they affect children.
"What it does do, though, is bring to life the human reality that lies behind bureaucratic terms such as 'asylum seeker' and 'dispersal'.
"For Tina, that reality was a disrupted and, sadly, very short life."
A Home Office spokesman said: "Our thoughts are with the family who have lost their child.
"We are committed to ensuring the safety and security of all those within the asylum system and working with local authorities to ensure children are safeguarded.
"Our new asylum contracts contain a number of improvements in relation to safeguarding and vulnerability and we will of course consider the full recommendations of the review in due course."