'Missed opportunities' to protect murdered toddler Lola James

• ITV Cymru Wales journalist Gwennan Campbell reports.

Lola James was a “happy, bubbly, beautiful” little girl.

She was two and a half years old. Her life had barely started. 

But in July 2020, her life was cut short.

Lola was the victim of a "brutal and extremely violent assault" by her mother’s boyfriend, Kyle Bevan, somebody she should have been able to trust, at home in Haverfordwest, Pembrokeshire.

Lola was pronounced dead on 21 July, 2020, aged two years and 10 months old, having been the victim of an "unprovoked" attack five days earlier.

Bevan, who had claimed Lola had fallen down the stairs, was jailed for life in April 2023 with a minimum term of 28 years.

Lola’s mother Sinead James, 30, was jailed for six years after being convicted of causing or allowing her daughter’s death.

The judge concluded Lola’s mother was asleep when the little girl suffered the injuries which caused her death but that she was aware that Bevan had been abusing Lola, “yet did nothing” to protect her.

Now, a review has found there were missed opportunities to protect the toddler.

The child practice review by the Mid and West Wales Safeguarding Children Board set out a series of failings, with reports closed without any real detail, overworked staff, visits not made when they should have been, and a lack of resources within Pembrokeshire Council's social services team.

The report said the “service was overstretched and morale was low” and as a result “an assessment of (Lola’s) needs was not properly undertaken by children’s services, as required, and the only identified service to support the family (TAF), was not actioned.” 

However, it goes on to say: “It is impossible to say what the content of a properly undertaken assessment would have included or what would have happened if TAF had become involved. Even if children’s services remained actively involved post March 2020, it cannot be said that the subsequent events of July 2020 would have been avoided.”

Bevan was known to the police since at least March 2019 for domestic incidents related to his own mother, who told the court he had an “anger problem”.

The review said concerns had been raised in January 2020 by a health visitor to Lola’s home, who said the mother was finding her daughter demanding, and at previous visits, she was unwashed, with her feet black with dirt.

While the health visitor submitted a multiagency referral form – to bring in social services – the review said there were a number of “missed opportunities” to arrange additional home visits, which could have allowed Lola’s well-being to be ascertained.

Those visits could also have uncovered that Bevan was living at the address, which James had not revealed to the team, and the condition of the home, which “would (on its own) have raised child protection concerns”.

Children’s Services opened a report on Lola which the review criticised as “lacking in detail and analysis”.

The board said a report had been dated February 2020, but it became apparent that the assessment had not been completed by the named social worker and had instead been created and closed by a team manager in March of that year.

The social worker named had been on sick leave, with the team “struggling under the pressure of the relentless workload”.

She told the review board that she had not anticipated that her assessment would be closed by her supervisor while she was off, as it was not usual practice.

The review found the closure of Lola’s case was “not appropriate”.

It said: "This is not a practice that was endorsed by children’s services at the time, or to date.

"The consequence of what happened in this case is that an assessment of (Lola’s) needs was not properly undertaken by children’s services, as required."

• Emma Sutton KC, author of the review, says an assessment of Lola James by social services was closed down in a "very unusual way".

It was also found that Lola’s father had not been contacted by social workers, nor had he been informed by police about incidents at the home.

Had he known, he suggested she could have been moved into his “bubble” during the pandemic.

The report admits Lola’s death may not have been prevented if the case had not been closed by social services or more health visits had been carried out, but more should have been done.

The report listed seven learning points and 11 action points for improvements to be made to prevent future deaths.

Actions recommended include ensuring adequate staffing levels and that information be better shared between agencies.

Pembrokeshire Council held a short press conference about the report but refused to take any questions from the media.

• Councillor Tessa Hodgson, cabinet member for Pembrokeshire Council, reads a statement to the media but refuses to take questions.

Councillor Tessa Hodgson, cabinet member for social care and safeguarding for Pembrokeshire Council, said: "Pembrokeshire County Council would first like to convey their sincerest condolences to the family of Lola James and to all those who have been affected by her murder, over four years ago.

"This review process, that we have fully and openly engaged with along with our multi-agency partners with whom we share safeguarding responsibilities, has been an opportunity for the local authority to reflect on its practice and to learn from the observations contained in the independent report.

"We would like to recognise the significant commitment and input of those who have taken part in the review process, and who have been involved with the family over the last four years.

"The local authority takes extremely seriously its duties within the safeguarding arena, and places the protection and support of the most vulnerable in society as its key priority.

"Whilst we would always strive to demonstrate good practice, there is always room for improvement and the opportunities that this review has presented us with, will allow us to improve how we work with vulnerable children and young people in the future."

Cllr Hodgson said the local authority had developed an action plan "to deal with the issues the review has raised for us" ahead of the report's publication, and "we have made considerable progress against that plan already".

She added: "In addition, we have established a social care improvement board, which includes amongst its membership locally elected politicians, senior officers and an external independent expert. This board will oversee delivery against the actions within that plan, with progress also being reported into local authority scrutiny committees and cabinet meetings.

"We hope also that the report, will contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities in the west Wales region and beyond.

"It is imperative that we take all opportunities to improve our services, and ensure that children and families receive the best quality of support available. Once again, Pembrokeshire County Council would like to extend its deepest sympathies to the family and all of those who knew Lola."

A joint statement on behalf of Pembrokeshire County Council, Hywel Dda University Health Board and Dyfed Powys Police said: “All agencies involved in this report wish to convey their sincerest condolences to the child’s family and to all those who have been affected by the murder of a child in such appalling circumstances.

"This 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.

“All agencies take very seriously the opportunities that this review presents, to consider our practice and improve how we protect vulnerable children.

“We hope that the report will also contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities."

Children's Commissioner for Wales, Rocío Cifuentes, said: "We’ve heard that Lola James had a passion for the outdoors, and a laugh that filled the room with joy. But amongst the failures documented in today’s report is a lack of focus on her experiences and needs, and a failure to take a child-centred-approach, at a time when she desperately needed the professionals around her to act quickly and decisively to keep her safe.

"Whilst the review’s recommendations centre around improvements required at a local level, for us, the review’s reach stretches far wider - it’s clear to us that there are national learning points from this report.

"Some, like inadequate information-sharing, are consistent themes in child practice reviews that point to a weakness in how the learning from individual cases effectively improves national practice.

"We continue to be deeply concerned about this element of our child protection system – despite us requesting time and again for clarity, the fact remains: we do not know who has responsibility for driving systemic improvements on the back of these reviews, and who is responsible for holding agencies to account for improving practice."

She also said she was worried about the pace of change, saying: "These investigations cover the most heinous actions against children, and yet we know from work we’ve done that there are actions from previous Child Practice Reviews that haven’t been fully implemented years after they were published. We need a much stronger system of clear ownership, clear direction, and clear accountability. Quite simply, there are serious questions for the Welsh Government, questions that I’ve asked consistently over the past two years, that remain unanswered."

A Welsh Government spokesperson said: "This is a tragic case and our thoughts are with everyone affected by Lola's death.

"We will carefully consider the learning identified by the Child Practice Review and ensure this is driven forward.

"A Single Unified Safeguarding Review system is being developed which will ensure the findings from all child and adult practice reviews are captured, shared and acted upon. We are also developing a National Practice Framework, to promote best practice and raise practice standards across services for children in Wales.

"Extensive work to transform children’s services is ongoing and we have been clear that now is the time for action and not further review."

Carl Harris, assistant director of NSPCC Cymru, told ITV Cymru Wales: "The report reminds us of the unspeakable actions of Kyle Bevan back in 2020 and of course the failure of Lola’s mother to safeguard her daughter who died at the age of two.

"Within the child practice review, there's opportunity to identify learning for professionals and agencies that are responsible for keeping children safe.

"Sadly, what we see in the review are recommendations around the same themes that we have seen many, many times before. These include assessment teams, front door teams of social services that are overstretched due to them being under-resourced.

"What we’ve got to remember is that these practitioners care deeply about the children they’re responsible for but owing to the fact that they have limited time to deliver on what they need to do, of course there’s a compromise and unfortunately then what we end up seeing is poor practice sometimes or practice that doesn’t reach the standard which we would hope for and then at times we have near misses and obviously in the worst of cases we have fatalities.

"The review of course talks about learning for professionals and agencies but safeguarding is everyone’s responsibility and isn’t just limited to those who work with children in various professions.

"It is the responsibility of communities that we live in to be that first line of safeguarding. So what I would urge anyone reading this is if you have concerns about a child or children that you know or that you see on a daily or even infrequent basis, don’t hesitate to contact the agencies that are out there to help."

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