Walsall Manor Hospital to hold fresh review into Kyle Keen death
An independent investigation is to be opened into the death of a 16-month-old toddler, following failures at a Walsall hospital.
Kyle Keen died in 2006 from a brain bleed after being shaken by his stepfather, Tyrone Matthews.
Matthews was sentenced to six and a half years for manslaughter a year later.
Walsall Manor Hospital said a new review would be undertaken to analyse how the incident was handled.
During the trial, the court heard Matthews, of Hatherton Street, Walsall, had a history of violence towards Kyle and Kyle's mother Kerry Mackintosh.
Kyle was admitted to hospital in June 2006. His life support machine was turned off a day later.
A post-mortem examination revealed he had been severely shaken, although Matthews claimed they had been play fighting.
In 2009, Walsall Manor was strongly criticised in a serious case review.
It said a week before Kyle's death, nurses and a junior doctor identified suspicious bruises on Kyle's body and wanted to refer the matter to social services.
But under the instruction of a consultant this was never done.
Nobody spoke to Kyle's natural father, Robert Keen, who was also suspicious about the bruising.
The serious case review said "nursing staff followed the advice of the paediatrician. On his instruction, they did not refer Kyle to the police or social services".
Mr Keen said he was never told of the hospital's failings in child protection procedures.
"I don't want anybody to go through what I have had to go through, what I and my family have suffered.
"I want the hospital to follow procedures and stick to the procedures," he said.
Hospital board minutes dating back to 2007 suggested the trust board was told wrongly that the bruises were due to sepsis.
The hospital has also admitted that it has only recently obtained a copy of the full serious care review.
In a letter to Mr Keen, new hospital chief executive Richard Kirby said it was standard practice at the time for the full report to be held by the safeguarding board, although the hospital did receive a copy of the recommendations and the executive summary.
Mr Kirby said: "A series of recommendations were made and acted upon at the time.
"We will be undertaking a further review of this tragic case to ensure that we all understand how this incident was dealt with and whether there are any further lessons for us to learn."
As part of the latest review, he has called for an independent team to consider whether the hospital was sufficiently open.
Mr Kirby is also concerned that information was not shared with Mr Keen.
The father, who has been trying to establish the full facts of the case, said he had still not managed to obtain his son's medical records from the hospital.
Dr David Drew, a consultant who saw Kyle on the day he died, was clinical director in the children's department at the time.
He said he continued to raise concerns about the case and his department with hospital management.
Dr Drew later lost a tribunal appeal having been dismissed for gross misconduct after emailing Bible quotes to colleagues.
During the hearings, he said the emails were used as an "excuse" to dismiss him after raising concerns about standards of care, including the treatment of Kyle Keen.
He said a further review carried out into the entire department in 2010 by the Royal College of Paediatrics did not mention the Keen case and he was the only one in the department allowed to see it.
"Kyle never figured in their report and we have never been able to find out why," he said.
"Because six months after the review reported, it was suppressed. The trust board were never allowed to see it and we have now found out that the whole Royal College Panel was made to sign gagging clauses by the trust."
In response, the hospital said the report contained personal information about individuals in the department and could not be widely disseminated.