Fiona Anderson case: 'Killed' children 'needed more help'
More could have been done to help three children thought to have been drowned by their mother before she fell to her death from a car park, a report has found.
Fiona Anderson, 23, died shortly before the bodies of her daughter and two sons were found in Lowestoft in April.
The children had been subject to a child protection plan since 2011.
A serious case review found the deaths were "completely unexpected", but more decisive action could have helped.
The report said agencies had "allowed the [intervention] process to drift".
Independent consultant Ron Lock, who conducted the review, examined how public agencies worked with the family prior to the deaths.
Social services and other agencies were alerted to Ms Anderson and her partner, Craig McLelland, because of concerns about their parenting abilities.
They were in communication over a three-year period, with a 14-month gap in between, when concerns diminished.
During that time, there were reports that Levina and her baby brother Addy had slept for 13 nights in a double pushchair while being fed only biscuits.
The report concluded that, while procedures were followed, Suffolk County Council's children and young people's services (CYPS) was not decisive enough.
Mr Lock found that attempts to engage with the family had failed, but there were no warning signs to suggest Levina, three, Addy, two, and 11-month-old Kyden were in immediate danger.
Court proceedings to remove Levina had been initiated but were withdrawn following a legal challenge and insufficient evidence.
However, the report states, the process led the relationship between the family and children's social care to become strained.
"Despite interventions by a number of practitioners, there was no success in effectively engaging the family in interventions by professionals", Mr Lock found.
"This meant that overall the implementation of the child protection plans was significantly compromised."
The report cited how Ms Anderson "specifically avoided professional interventions", distrusted social services and rebuffed support from nursery staff because "she thought the children would be exposed to sexual abuse".
The report found that almost three years before the children's deaths, in June 2010, concerns had diminished sufficiently for formal involvement to cease.
"Clearly, if the children had been placed in care this could have avoided the tragic outcome," the report said.
"But there was never any guarantee that an application for a care order for the children would have been successful.
"It was nevertheless concerning that a clear decision was not made by CYPS in respect of the need for a legal intervention and instead allowed the process to drift in a most unconstructive way."
Mr Lock stated there had been "no known history of either the mother or the father intentionally causing physical harm to the children, or any self-harming episodes by the parents themselves".
"In this respect, the deaths of the children and their mother were completely unexpected," he wrote.
"Psychological and psychiatric" assessments of the mother were proposed and discussed with her, the report concluded, but "were never achieved because of her reluctances".
It added: "At the time of writing there has been no coroner's inquest, although current evidence would suggest that the mother took the lives of the children prior to taking her own life. "
The report identified 13 "learning points" aimed at preventing future repetitions in similar cases.
Peter Worobec, independent chair of the Suffolk Safeguarding Children Board, said "things have and will continue to change".
"The action already taken to eliminate drift in such cases and ensure all child protection cases are subject to robust management oversight, particularly in Lowestoft, is laid out.
"We have identified a further 21 actions that will be taken to ensure that practice is improved."