The death of a six-week-old baby who was killed after being repeatedly assaulted by her mother's boyfriend was not predictable, a report has concluded.
Judge Howard Llewellyn chaired a significant case review into the death of Alexis Matheson who was attacked by Mark Simpson at the home he shared with the baby's mother in Aberdeen. Alexis died in hospital in Edinburgh on December 10 2007, less than two months after being born
Simpson was charged with assaulting her on various occasions between November 8 and December 9 by seizing hold of her, shaking her and compressing her chest, leaving her so severely injured that she died. He was found guilty of her murder and was jailed for life in November 2010, being told that he must spent at least 20 years in prison.
In the significant case review, Judge Llewellyn considered if the baby's death could have been prevented had signs of non-accidental injury been detected earlier. He said: "I conclude that her death was not predictable from the information available to practitioners."
While he concluded that Alexis's injuries may have been treatable in the few days before her death, he said: "Her survival was possible rather than probable. I do not therefore conclude that her death would have been prevented."
The review took place after Lord Uist, the judge during Simpson's trial, said that some of the evidence gave him serious concern about how the health service dealt with Alexis and whether her death could have been prevented had her injuries been spotted earlier.
Judge Llewellyn concluded that NHS staff are "committed and hard-working professionals who aim to deliver the best service they can to the public". There is "no evidence to indicate there were significant or mounting concerns being expressed by anyone" over Alexis's health or Simpson's involvement with the baby, he said.
Judge Llewellyn said he found no evidence of significant staffing difficulties within either the midwife service, the health visiting service or the GP practice that Alexis was seen at.
But he recommended that the telephone appointment system operated by GPs be reviewed so that in future it can be determined if the patient is a baby and who should then be given an appointment within 24 hours.
NHS Grampian has already introduced changes in the wake of Alexis's death. Communication between health visitors and GPs has been improved and they have been provided with better child protection training, the health board said. It is also working with Robert Gordon University in Aberdeen to develop child protection in nursery and midwifery education.