Report on killings of children by mentally ill mother 'is scandalous'

Jimi Ogunkoya's son and daughter died at the hands of his former partner after doctors failed to spot the danger and social workers allowed her unsupervised access.

Vivian Gamor, 29, had stopped taking her medication days before she killed Antoine, 10, and three-year-old Kenniece at her Hackney flat on 27 January last year.

Antoine was bludgeoned with a claw hammer after his mother tried to strangle him. She suffocated his sister with clingfilm and left her in a bin bag before setting fire to the flat and calling 999.

Mr Ogunkoya cared for the children and had repeatedly told the authorities of his fears about Gamor, who believed her real children had died in the womb and were swapped at birth.

But Hackney social services allowed her visiting rights against his wishes after doctors failed to realise she posed a physical threat to the children, partly because she did not live with them.

It also emerged today that the number of visits supervised by social services was cut from three to one after a social worker went on holiday.

But an independent report into the tragedy published today concluded that no "single judgment or action within any agency triggered or failed to prevent" the killings. Instead the "serious case review" published today by the City and Hackney Safeguarding Children Board identified "organisational and individual failings" within the various agencies involved. It recommended:

Better communication between mental health services, social workers and other agencies.

Child protection procedures should be applied in cases of parental delusions involving a child, even if they do not live together.

Social care of children should be considered whenever a parent's delusional thinking involves them.

Multi-agency meetings focusing on the risk to the child before a mentally ill parent is discharged from hospital.

Greater involvement of a child's other parents or carers in risk assessment.

Better training and record keeping.

But Mr Ogunkoya, 32, branded the report "inaccurate, insensitive, inadequate and scandalous" and called for a public inquiry. The former council worker had to give up his job after his children's deaths and despite counselling describes himself as "a broken man".

He hit out at the decision not to make the full report public, taken because publishing medical records would breach data protection laws. Mr Ogunkoya, of Hackney, said: "I have suffered the most painful thing in this life. My children are gone and we have not had time to grieve because of all these issues surrounding their deaths.

"I understand that nothing will bring them back but in the interests of the public and my family we need a wider inquiry into this case."

Gamor had been sectioned in September 2006, several months before the killings, after claiming she was "Jesus's twin" and the children were not hers. In other incidents she attacked a hospital worker, cut off her daughter's hair and threatened her half-sister with a knife.

But she responded well to treatment and was released in October after saying she wanted to re-establish contact with her children. When she was released doctors did not assess the physical risk she might pose to her children and she was treated accordingly by social services.

The one supervised contact session shortly after her release was considered a success and they were allowed to stay overnight with her for the first time two weeks before she killed them.

The report found that only if doctors had identified a physical risk to the children, which would then have been taken into account by social services, could the tragedy possibly have been averted.

Gamor was detained indefinitely after admitting manslaughter on the grounds of diminished responsibility at the Old Bailey on 1 August last year.

Following the abuse and murder of eight-year-old Victoria Climbié in Haringey in 2000, an inquiry report by Lord Laming made a series of recommendations. But Mor Dioum, director of the Victoria Climbié Foundation, said: "This case shows that in many areas basic good practice that could stop children dying has not been implemented."

Hackney Council said today that all the recommendations of the new report had already been brought in.