Catalogue of failures exposed over toddler in drugs tragedy

Ricardo Munio died after being poisoned at his home in Leeds by a massive dose of his mother’s anti-depressant tablets.

Now a serious case review by the Leeds Safeguarding Children Board has laid bare a litany of blunders by nine different agencies involved with the toddler and his family in the years leading up to his death.

They include the “inadequate” response by staff at the school of Ricardo’s older sibling, who were told on six different occasions about physical abuse at home. Police and a housing support worker also left the sibling in the care of mother Sophie George while she was drunk.

Officers also attended 41 domestic incidents at the family home in North Farm Road, Gipton, involving the children’s parents, many of which the local social work team was not informed about.

Both children were also seen to have “unexplained injuries” on several occasions.

The review, which names Ricardo only as “Child Q” says: “With hindsight one should not be surprised that a serious incident occurred and the independent author concludes that appropriate responses to earlier concerns about the family may well have prevented this tragedy.” It adds: “The fact is that the older sibling had been an invisible victim of abuse for a number of years and both children continued to suffer abuse after the birth of Child Q. None of the issues surrounding the older sibling or the family were ever resolved. Had they been so this may have resulted in a more positive outcome.”

An inquest in March heard that Ricardo was taken to the Accident and Emergency Department at St James’s Hospital, Leeds, but was pronounced dead just before 4pm on December 11, 2008.

Toxicology tests revealed levels of anti-depressant Dothiepin in his system which were the third highest ever recorded at a lab in Sheffield.

A search of the family home, where Ricardo lived with his mother and father James Munio, found two empty blister packs, which had contained the tablets, secreted behind a panel next to a toilet.

Miss George later admitted a charge of child neglect and was subsequently sentenced at Leeds Crown Court to a two-year supervision order.

The review makes 10 recommendation to the nine agencies involved Children and Young People’s Social Care, Leeds City Council early Years Service, Education Leeds, Leeds Refugee and Asylum Seeker Service, Leeds City Council Environments and Neighbourhoods, Leeds NHS Trusts, West Yorkshire Police, the UK Border Agency and the Independent Counselling Service.

Jane Held, chair of the Leeds Safeguarding children board said: “The death of Ricardo was a tragic loss for his family and our sympathies are with them, both then and now.

“Although we will never know exactly what happened just before his death, nine agencies were all involved with him and his family over a period of several years and it was vital that we commissioned a thorough, detailed and independent review of the circumstances around Ricardo’s death to identify what lessons could be learned.

“We are very sorry that we did not do enough together to support Ricardo and his family or to protect Ricardo. The review is rightly critical of all agencies, and we accept the findings of the review fully.

“It is possible that if things had been different an incident such as this could have been avoided.

“All of the agencies accept the findings of the review without reservation.

“Since Ricardo’s death four years ago, much has been done locally to change how we work together to reduce the risk of something similar happening again. The learning from that time has made us determined to do better. All the review’s recommendations have been accepted, and acted on, and the difference that this has made is a regular question we ask each agency.”