Kaylea Titford: Disabled teenager's suffering and death 'avoidable', safeguarding review reveals

• Dr Donna Peach, Independent reviewer, said she thinks Kaylea's needs "weren't met as well as they could have been."

A safeguarding report into the death of a disabled teenager who was found in "filthy" conditions has concluded her suffering was "avoidable" and improvements must be made in future.

Kaylea Titford, who suffered from spina bifida, was found dead at her home in Newtown, Powys, in October 2020, after her parents allowed the teenager's condition to deteriorate so much she died.

A post-mortem examination found Kaylea to be grossly obese and immobile and that extensive inflammation and infection had led to her death.

The 16-year-old weighed 22st 13lb with a BMI of 70 at the time of her death in October 2020.

Her mother Sarah Lloyd-Jones, 40, was initially jailed for six years, while her father Alun Titford, 45, was told he would spend seven years and six months behind bars in March.

A Court of Appeal later increased the Sarah Lloyd-Jones' sentence to eight years and Alun Titford's to 10 years after the circumstances leading to her death "can only be categorised as extreme".

The Mid and West Wales Regional Safeguarding Board, CYSUR, has now published its review into Kaylea's death.

The need for "professional and organisational learning" and "improvement in future interagency practices" were identified in the 25 page report.

It also revealed how a lack of coordinated care and support, alongside living in a rural location were key factors leading to Kaylea's death.

Dr Donna Peach, the independent reviewer, said that one of the important things the review did was "capture Kaylea and her energy and vitality and we wanted to put some balance into not the way she died but the way she lived her life with this chronic disability."

She continued: “We found there were missed opportunities of things such as monitoring Kaylea’s weight, having better monitoring of her skincare and there was a lack of coordination to predict some of her needs from adolescent to adult hood.

“I think that her needs weren’t met as well as they could’ve been.”

Dr Peach added that the pandemic did create "a significant period of isolation for her [Kaylea] and that had a huge impact on her.

“I think the period of isolation that reduced the family’s infrastructure and Kaylea’s infrastructure which supported them, one would expect some of those things would’ve been picked up. It had a contributory factor to the outcome”.

The review recounts Kaylea as a "wonderful, determined, fun, and headstrong girl who, despite her significant congenital disabilities, wanted to be treated as normal" and excelled when playing sports.

But a timeline of events reveals how Kaylea's health deteriorated and her school attendance dropped from 98% at the beginning of 2019 to 70.8% in mid-November that year which her parents explained to teachers by health needs and bullying experienced in school.

Kaylea received informal counselling and her school attendance slightly increased to 82% but by the following March, Kaylea stopped attending school in person after being identified as a vulnerable pupil who needed to shield during the COVID-19 pandemic.

Throughout April and July 2020, staff phoned Kaylea’s parents weekly but there were only two recordings where it was explicit that the child was spoken to directly.

From September, the school were in contact daily with Kaylea's mother and a phased return to school was planned for 7 October.

She died days later.

One of the key findings was how Kaylea had no coordinated care and support that would have been expected for a child with a lifelong disability like spina bifida.

Whilst multiple health professionals and agencies were involved in the delivery of her health care, the review reveals it was not joined up and no single agency or practitioner had a holistic overview of her needs.

The Board has recommended that to stop the void in provision happening again in the future, any decision on services provided to a child with complex needs should be made by agreement of multiple agencies.

Powys County Council, Powys Teaching Health Board and Dyfed Powys Police have offered their sincere condolences to the child's family.

"The review has been an opportunity to reflect and share learning amongst all partner organisations and practitioners on a multi-agency basis, and we acknowledge the commitment and contribution of those who have taken part in the review process.

"We hope that the report will contribute to wider ongoing learning in relation to a number of key issues identified in the report so that children and their families are supported fully."

Mid and West Wales Regional Safeguarding Board say they are overseeing a 'regional action plan' to ensure that lessons continue to be learnt from Kaylea's death.

An NSPCC Cymru spokesperson said: “It is incredibly distressing to read Kaylea’s voice was not heard and her lived experience not seen.

“Research shows that young people with disabilities are three times more at risk of abuse and this review shows how crucial it is for their needs to be adequately assessed and met by all agencies.

“The review reflects our previous concerns about the impact of Covid-19 increasing the vulnerability of some children to the risk of abuse and neglect and affecting their ability to seek help and professionals’ ability to respond.

"It is vital the recommendations made by this review are fully implemented so that everything possible is done to prevent such tragedies from happening in the future."

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