Powys County Council has been given a number of recommendations in the report into the death of Kaylea Titford.
Kaylea died in October 2020 after being chronically neglected by her parents. She was found “to be grossly obese and immobile” with “extensive inflammation and infection leading to her suffering and ultimate death”.
A report by Dr Donna Peach found social services had not put together a plan to support Kaylea.
Dr Peach wrote: “Although multiple health professionals participated in the delivery of her complex health care, this was not coordinated by a single agency or practitioner who had a holistic understanding of her complex health and care needs."
“Agencies rely on each other and a child’s parents to request a care and support assessment” and they added Kaylea “would have benefitted from an assessment to identify her care and support needs.”
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Powys County Council was found not to know if Kaylea was included in the disability register but said it was unclear “if or how inclusion would have directly benefitted her”.
They recommended that the council “should have a system that identifies the children with disabilities in their region who are likely to need care and support.
“This information should be used to shape allocated resources and the services available to children in Powys.”
They found that “multiple agencies” had discharged Kaylea from their service, and “there is no evidence of any consideration to initiate an assessment of her needs to enable that coordinated transition to adult services.”
“Many of her needs could be predicted, but the overarching coordination of services was not consistently available," Dr Peach wrote.
“Transition planning could have helped consider her changing needs as she moved into adulthood and support her increasing independence, while recognising the complexity of her disability.
"If a child with a lifelong disability is discharged from services without any oversight it limits the vital cohesive, holistic care, treatment and support they need from paediatric to adult care.”
The report recommended that “all agencies undertake a review of their existing training programmes and policy guidance to ensure the duty on all practitioners, regardless of barriers, to speak to and communicate directly with children, is understood.
“Their responsibility to engage with and accurately record any communications must be explicitly clear and understood by those responsible for delivering and providing services to children and their families.
It also said the council should “ensure it has sufficient resource to deliver a meaningful and effective service. “
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