Baby starved to death by parents as health officials 'missed chance to save her'

Thirteen-month-old Aaron Gilbert died from severe brain damage after suffering an horrific campaign of abuse at the hands of Andrew Lloyd.

One neighbour later told police that Aaron was so deformed by his injuries before his death that he 'looked like the Elephant Man'.

Yesterday a damning report concluded that care agencies missed numerous opportunites to intervene.

A case review into Aaron's death highlights the tragic failure of the police, social services and health workers to identify Lloyd as a threat to the public.

Lloyd, 23, was last year jailed for life with a recommendation he serve a minimum of 24 years.

The boy's mother, Rebecca Lewis, is serving a six-year sentence after becoming the first British woman to be convicted of allowing her child to be murdered by a violent partner.

She regularly watched her boyfriend Andrew Lloyd beat the little boy, causing more than 50 injuries, and once saw him pick up Aaron by his ears and throw him across the room.

The court heard that Lloyd would swear at the boy and blow smoke into his face. He once promised 'to smash your little head in'.

Giving evidence, Lewis said Lloyd would flick the baby's ears and feet, making him scream in pain, and that Aaron would 'shiver in fright' at the sight of him.

The shocking details that emerged in the trial led to an urgent case review by the Swansea Safeguarding Children Board.

It revealed that Lloyd had regularly been in trouble with the police as a teenager, had convictions for violence, and abused drugs and alcohol.

But essential details about Lloyd were not place on the Police National Computer, and he was not identified as a risk to the public or to his partner and children.

The report added that the police, mental health services and the probation service had failed to share vital information on Lloyd.

After Lloyd moved in with Lewis, a cycle of abuse began which could have been exposed on a number of further occasions.

In one case a social worker failed to instigate an immediate child protection inquiry despite being warned Aaron was suffering bruising.

Three weeks before Aaron's death, his mother took him to A&E with an injury but left the hospital before being seen.

A planned home follow-up visit as a result of that never took place because of staff sickness.

Health professionals had seven separate incidents of contact with Aaron in the weeks before his death, but did not discover that Lewis was living with Lloyd.

The report concludes: 'Andrew Lloyd was not identified as a significant risk to the public and to his partner and children.' The report recommends that Swansea Social Services look at the system and staff involved in making critical child protection decisions.

It says procedures for sharing information within the Swansea Safeguarding Children Board should be reviewed to ensure they fit the purpose, and the procedures for calling a domestic violence multi-agency risk assessment conference should be reviewed.

The failings of the process for placing details on the Police National Computer should be raised, with a recommendation that the present process be audited and reviewed, it adds.

Mark Roszkowski, chairman of Swansea Local Safeguarding Children Board, said yesterday: 'The murder of Aaron Gilbert by Andrew Lloyd was a terrible tragedy.

'All the agencies who had contact with Aaron are learning the lessons.

'What comes out of the report is that all the agencies must share information. We each held various information but the jigsaw never came together.'

A spokesman for the National Probation Service for South Wales said: 'Whilst many of the procedures in place to protect children worked properly, the tragedy of Aaron's death demonstrated again the importance of the closest inter-agency working when protecting vulnerable children.

'We are wholly committed to implementing the recommendations from this inquiry.'