A serious case review into the death of tragic Thornhill toddler Summer Mai Rogers-Ratcliffe has been published.
Last year a coroner recorded that she was unlawfully killed by a blow to the head, after she was found close to death in her cot in 2012.
The review, by Kirklees Safeguarding Children Board, looked into the work of health and care agencies that dealt with Summer before she died.
It found her death could not have been prevented or foreseen but recommendations were made to the agencies involved.
Bron Sanders, the independent chairman of the board, said: “This was a tragic case involving a child who suffered a serious head injury and subsequently died at the age of one year and nine months.
“The board agree with the key finding of the independent author, who states that ‘professionals could not have foreseen or prevented the child’s death’.
“It is important to stress that the purpose of the Serious Case Review was not to establish the cause or origin of the fatal injury sustained by the child. That is not the remit of any Local Safeguarding Children Board.
“The purpose of the review was to look at the work of all agencies who were involved with the family and to establish whether any improvements could be made to working practices as a result of the case.
“It should be noted that a court order is in place which places restriction on the amount of information that can be shared in the public domain and this report has been written in accordance with this Reporting Restriction Order.”
The recommendations included clearer directions to health trusts on how to identify and deal with injuries on children that may not have been accidental and a stronger system to flag up children with safeguarding concerns.
The report considered the time from Summer’s birth in May, 2010, to her death on February 28, 2012.
It said that Summer’s mother, Victoria Rogers, took her to baby drop-in sessions and relevant GP appointments in the earlier months of her life, but referred to a visit to the walk-in centre at Dewsbury and District Hospital in which Summer was treated for an unexplained burn.
It noted good practice from burns unit staff and the health visitor, who completed an assessment of Ms Rogers in January, 2012, when she reported feeling distressed and was prescribed antidepressants.
Last July a coroner said there was an overwhelming likelihood that the blow to the head that killed the toddler was non-accidental, caused either by her mother Victoria Rogers or her then boyfriend Craig Sharp.
Later that month it was revealed a family court judge had ruled that Ms Rogers caused her daughter’s death on the balance of probabilities.
But the Crown Prosecution Service has said that there is not enough evidence to stand up the case in a criminal court and no one has been prosecuted.