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19 June 2014, 17:27 | Updated: 19 June 2014, 17:35
The death of a baby boy at a hospital in Walsall might have been avoided if hospital doctors had spoken out over concerns for his care, an independent report has found.
Kyle Keen was 16 months old when he was admitted to Walsall Manor Hospital in June 2006 with fatal brain injuries, only days after doctors had discharged him.
Despite being transferred to a specialist paediatric unit in Stoke-on-Trent, the youngster died on June 30.
His step-father Tyrone Matthews, 32, had inflicted Kyle's injuries by severely shaking him and later admitted manslaughter, for which he was jailed at Wolverhampton Crown Court in 2007 for six-and-a-half years.
Kyle's mother Kelly McIntosh admitted child cruelty by neglect and was given a six-month suspended prison term.
The chief executive of the Walsall Healthcare NHS Trust, which runs the hospital, has apologised.
A damning independent report into the hospital's handling of the case concluded: "It is clear that there is a significant probability that this death could have been avoided if the staff at Walsall Manor Hospital had referred Baby K (Kyle) to social services on June 21 to 24 2006 and action had been taken to intervene.''
The report said "serious errors of judgment'' by the hospital's staff may have contributed to the boy's death, but found there was no evidence anyone had been formally disciplined over those failings.
It also found staff should have pursued their concerns and followed the hospital's safeguarding policy "even though a senior colleague disagreed''.
It described the trust's response to be "wholly inadequate'' both in its handling of the initial admissions, and then later in failing to "act decisively to respond to lessons learned'' flagged up by its own investigations and a separate serious case review.
The report, authored by Cordis Bright consultants and commissioned by Walsall Healthcare NHS Trust, Walsall Council, and the local safeguarding children board, further stated there was evidence the hospital's own staff were ignored when they raised concerns about the baby's welfare.
Kyle was originally admitted to the hospital on two separate occasions in the fortnight before his death, when staff noticed unexplained bruising on his little body.
The report concluded there was a risk "medical and nursing staff were not heeded when they voiced concerns about possible non-accidental injury of Baby K'', and the trust's response had been ``seriously inadequate''.
The hospital's record-keeping was also patchy, contradictory and "poor'', with errors even uncovered in the NHS trust's own follow-up analysis.
It has listed 14 recommendations and noted the hospital has made "considerable effort'' to improve procedures for safeguarding children since 2013.
But it further pointed to outstanding and "significant concerns''.
The review found that on June 13, Kyle was treated at A&E with a leg injury after the parents told doctors he had been injured on a trampoline.
On June 21, Kyle was admitted to A&E after his mother told medics he had been unwell for five days.
Nurses noticed bruising on his body which a consultant paediatrician put down to sepsis.
Two doctors and a senior nurse again pointed out Kyle's bruising but a "consultant over-ruled (their) concern'', the report stated.
On June 25, actions to alert the health visitor and a discussion to refer the case to social services were not followed through and Kyle was discharged without further intervention.
The following day, a doctor and a nurse repeated their concerns but the consultant paediatrician did not act.
When Kyle was admitted "gravely ill'' for the final time on June 29, no mention of the bruising was found in the hospital records, and he later died after being transferred to Stoke.
Nearly eight years after the little boy's death. the senior consultant involved is now to be the subject of an assessment to "ensure he is fully able to undertake his role'', the hospital trust said.
Richard Kirby, the NHS trust's chief executive, "apologised unreservedly'' to Kyle's father Robert Keen for his son's poor care, the failure to refer to social services, and the subsequent failings in the hospital's own follow-up investigations.
He said "significant improvements'' had been made in the way records were kept, procedures followed, and the manner in which the hospital, council children's services and the safeguarding board worked together
Mr Kirby added: "We recognise that an apology alone is not sufficient and I hope that we have been able to demonstrate to Mr Keen our commitment to act on what we have learnt from this review.''
Robert Lake, Walsall Local Safeguarding Children Board's independent chairman, also apologised, adding the board had made improvements since Kyle's death.