PFD report

Lily-Mai HURRELL SAINT GEORGE · Prevention of Future Deaths report

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Issued 10 Feb 2021•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Failure to prevent discharge into unsupervised parental care despite professional concerns
    Part of recurring concern: Unreliable hospital discharge processes
  2. Delay in implementing an agreed residential placement
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to prevent discharge into unsupervised parental care despite professional concerns

Wider context from the report

“Many healthcare and other professionals expressed the view that Lily-Mai should not be discharged into the unsupervised care of her parents, but Haringey Children’s Services nevertheless facilitated that discharge from hospital on Thursday, 25 January 2018. Lily-Mai suffered her fatal injuries six days later. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delay in implementing an agreed residential placement

Wider context from the report

“A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit, with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026