Sheriff finds ‘systemic failure’ by council after death of girl, 13

There was a “systemic failure” in the way a council handled the case of a 13-year-old girl who later died after her mother failed to seek medical treatment for her, a sheriff has found.

Robyn Goldie developed peritonitis and died on July 26 2018, having suffered a perforated duodenal ulcer after her mother Sharron Goldie failed to seek medical help.

Goldie, 49, who left her unwell 13-year-old daughter at home while she went to the pub, was jailed for three years and six months when Lord Beckett sentenced her at the High Court in Edinburgh in October 2020.

She had previously pleaded guilty to wilfully ill treating and neglecting her daughter in a manner likely to cause her unnecessary suffering or injury to health between July 12 2017 and July 26 2018.

A fatal accident inquiry (FAI) found Robyn’s death might have been avoided if her mother had sought medical help for her when she became unwell.

The inquiry into the death of Robyn also found “systemic failure” in the way North Lanarkshire Council handled her case, though this did not contribute to her death.

The Lord Advocate decided it was in the public interest to hold a discretionary FAI into the death.

In her determination, published following the FAI at Hamilton Sheriff Court, Sheriff Linda Nicolson found a reasonable precaution would have been for Robyn’s mother to have sought medical attention for her or, at least, allowed her to access medical attention.

She said: “Had that precaution been taken, it might realistically have resulted in the death being avoided.”

The sheriff found there were were no defects in any system of working which contributed to the death.

However she found North Lanarkshire Council social work policies and procedures, in place at the time, were not complied with in that a written comprehensive assessment, a written child’s plan, and adequate supervision of workers were lacking.

The sheriff said child protection measures should have been put in place, and a referral made to the Scottish Children’s Reporter Administration, at an earlier stage than they were.

She concluded: “I conclude that there was systemic failure on the part of social work to the extent of failure to comply with policy and procedures in Robyn’s case.

“That included not only the lack of a written comprehensive assessment and child’s plan but also a lack of supervision.

“However, the evidence did not support that the systemic failure contributed to Robyn’s death.”

Her determination states a number of changes have been implemented by the council or are in the process of being implemented.

The sheriff said she is satisfied that the changes made by the council address the issues of concern for the inquiry.

A spokesperson for North Lanarkshire Council said: “The death of Robyn Goldie was a tragedy. The sheriff found that Robyn’s death could have been prevented by her mother seeking appropriate medical assistance. Robyn’s mother was convicted of neglect and ill-treatment at the High Court in 2020.

“However, the sheriff also found that some of the systems of work used by the council were not effective or fully complied with, and some decisions about Robyn’s case could have been taken earlier.

“A serious case review after Robyn’s death made similar findings. The sheriff concluded that alternative approaches would not have prevented Robyn’s death, and has made no recommendations to the council as part of the inquiry.

“The council agrees with the sheriff’s findings and those of the serious case review. New systems of work, both nationally and within the council, have been adopted with the aim of improving recording, sharing of information and decision-making.”

As part of the charge Goldie pleaded guilty to in 2020, she admitted failing to provide her daughter with adequate food, clothing or heating, hitting her, and permitting her to smoke cannabis and drink alcohol.

Goldie, from Wishaw, North Lanarkshire, also admitted exposing her to unhygienic living conditions including cat urine and cat faeces, which led to her getting fleas.

The court heard Goldie suffered a serious traumatic brain injury when she was nine, which affected her cognitively and physically and has had an impact on her ability to manage over the years.

Prosecutors accepted Goldie’s not guilty plea to a charge of culpable homicide.

Describing July 26, the day Robyn died, Lord Beckett told Goldie: “Your daughter was in pain that afternoon, you gave her a painkiller and went to the pub.

“By the time you came home she was slumped on the sofa but you and your friend went into the garden to have a drink because the weather was nice.

“She was dead an hour later.”