The death of a three-year-old boy whose mother killed him and dumped his body in a suitcase could not have been predicted, a significant case review has found.
Mikaeel Kular died two days after being beaten repeatedly by Rosdeep Adekoya following a family day out in January 2014.
After discovering his lifeless body on the floor of their Edinburgh home in Ferry Gait Crescent, she put it in the suitcase and drove about 25 miles to Kirkcaldy, Fife, to hide it in woodland behind her sister's house.
She dialled 999 to report him missing to police, sparking a major two-day search operation involving the emergency services and hundreds of local people who volunteered to help.
Adekoya, then 34, was jailed for 11 years last August after pleading guilty to a charge of culpable homicide and a second charge of attempting to defeat the ends of justice. She had initially been charged with murder.
Fife and Edinburgh Child Protection Committees commissioned an independent significant case review to establish whether the care and protection systems involved with Mikaeel and his family could or should have foreseen the circumstances leading up to his death.
It found that Adekoya's behaviour towards her son was "unprecedented and out of character".
The family lived in Fife before moving to Edinburgh and Fife social work services were responsible for the case at all times.
Between February 2012 and July 2012, Fife social work and NHS Fife health visiting services carried out joint home visits after concerns were raised twice, which the report said showed good inter-agency practice.
However, there was no multi-agency meeting between professionals in contact with the family which, had it taken place, "would have ensured a comprehensive assessment of need and risk and informed what intervention was necessary".
Mikaeel was taken into foster care in July 2012 after Adekoya left her children unattended and he remained with foster carers until August 2013, when social work services were waiting for a Children's Hearing before returning the boy to his mother's care.
The report noted that while waiting for the Children's Hearing in August, contact arrangements were not increased.
The review team felt that this should have been undertaken and used as an opportunity to test out and monitor his mother's ability to manage her parenting responsibilities.
Once Mikaeel, referred to as MK, had been returned to his mother the family were visited five times by Fife social work and twice by the Edinburgh health visitor, with the professionals finding no factors suggesting a level of risk that required child protection intervention.
The review concluded that "the circumstances that led to MK's death could not have been predicted".
The report identified examples of good practice but also identified 13 areas for future learning and action for NHS Fife, Fife social work services and other organisations including the Scottish Government.
Steve Grimmond, chair of the joint Chief Officers' Group of Fife and Edinburgh, which agreed the remit of the review, said: "Social workers and health professionals involved in the case have been greatly affected by this tragedy.
"They care very deeply about what they do and the people they support.
"The report acknowledges the challenges involved for staff going through periods of organisational change while carrying heavy caseloads.
"All agencies will consider how we can improve support to staff at these times and make sure robust processes are in place to review and assess the impact of change within our organisations.
"The report does make a number of recommendations around the sharing and management of information, including asking the Scottish Government to consider national guidance around the transfer protocol for non child protection cases between local authorities. We're keen to support this in whatever way we can.
"Finally, we commissioned an independent significant case review to make sure we learn from this case.
"We fully accept the report's findings and we are taking every opportunity to improve and strengthen our practices."
The full report is not being published as it contains detailed, personal and private information, although a summary has been released.
Professor Scott McLean, NHS Fife executive lead for children's services, said: "NHS Fife accepts today's independent report findings in full.
"The report highlights that professionals communicated well with each other and worked collaboratively to care for Mikaeel and his family.
"It clearly states that there is no evidence that health or other professionals could have predicted the tragic death of Mikaeel.
"We are committed to learning from this case and further strengthening areas of practice."
A Scottish Government spokesman said: "The sudden, un-natural death of any child is a tragedy and the untimely death of Mikaeel Kular continues to reverberate across Scotland and in particular, the communities in Fife and Edinburgh where he lived.
"The Scottish Government therefore welcomes the urgency with which this significant case review was undertaken and its speedy conclusion and focused actions, which we are sure will now be considered and acted upon by all the appropriate agencies timeously.
"We accept the recommendation directed at the Scottish Government and we will consider the implications of the report very carefully.
"We are currently consulting on guidance and secondary legislation accompanying the Children and Young People (Scotland) Act which will help meet the recommendation.
"The Scottish Government takes seriously its responsibilities in relation to ensuring the safety and wellbeing of all of Scotland's children, including those who are most vulnerable and at risk of harm.
"We have worked, and will continue to work with, partners and through parliament to strengthen how statutory agencies and children's services work together to identify and respond early to concerns about a child's safety or wellbeing, including most recently through the Children & Young People (Scotland) Act."
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