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Baby's death leads to safeguarding and record-keeping improvements at Walsall Manor Hospital

Action to improve safeguarding and record-keeping at Walsall Manor Hospital is being rolled out after serious errors of judgement were made over the safety of a baby who was sent home and later died.

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Kyle Keen, aged 16 months, was admitted in June 2006 with a brain bleed. He had been shaken by his stepfather Tyrone Matthews, who was later sentenced to six-and-a-half years in prison for manslaughter.

An independent report earlier this year found there were serious errors of judgement that may have led directly to further injury to Kyle after his hospital admission on June 21.

It said staff who raised concerns about suspicious bruises on his body should have pursued the matter further even though a senior colleague disagreed - and that record keeping at the time was poor, inadequate and contained numerous omissions.

A separate Walsall Healthcare NHS Trust report giving details of what action is being taken to address the recommendations relating to Kyle's case, due this month, will not now be ready until March. But bosses insist progress is being made.

Trust chief executive Richard Kirby said: "Many of the recommendations from the independent review report about improving our processes have already been implemented and action on any remaining recommendations is on target. We will be reporting fully on progress as part of the review in March."

Work to improve the quality of clinical record keeping was also noted in a recent Care Quality Commission inspection.

Mr David Drew the former head of the Manor's paediatric department who later claimed he acted as a whistleblower in the case of the toddler said: "It has taken the trust eight years to acknowledge its fault in this matter. A few more weeks will probably make little difference."

Mr Kirby, who was not in charge at the time of the tragedy, has given an unreserved apology to the child's biological father Robert Keen for the failure to refer Kyle to children's social care in 2006.

The hospital was previously criticised in a serious case review in 2009 after it emerged that a week before the baby's death, nurses and a junior doctor spotted suspicious bruises on his body. They had wanted to refer the matter to social services but under the instruction of a consultant no report was issued.

He was again taken to the hospital on June 29, 2006 and transferred to the University Hospital of North Staffordshire where he died the following day. Matthews, then 25, denied killing him but admitted the lesser charge of manslaughter.

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