Four young children who died in a horror house fire after their parents fell asleep were so neglected that they only communicated by grunting and sustained dozens of accidental injuries, a report found.
Riley John Holt (eight), Keegan Jonathan Unitt (six), Tilly Rose Unitt (four) and Olly Unitt (three) died when a fire broke out in their family home in Stafford, Staffordshire last February.
Her youngest brother, then only two years old, survived the tragedy.
A serious review of the way agencies worked with the family found that while the children lived in "utter chaos" the children only believed in the mother's word and did not question the evidence before them.
Now the Stoke-on-Trent and Staffordshire Safeguarding Children Board has determined that social welfare services policies have "not been followed" and that the children have "suffered significant harm through neglect".
The parents were previously arrested by the police on suspicion of manslaughter through gross negligence.
In August, however, prosecutors announced that they would not take any further action.
Other findings of the board were:
- The house is "quiet" although five small children live there;
- There was an overwhelming smell of smoke among the children.
- Parents kept canceling and changing appointments with health visitors.
- Concerns about children in diapers that they don't wear often enough have changed.
- The nature of the injuries sustained would normally raise concerns about potential abuse& # 39 ;;
- Mother "laughed on their faces" when professionals mentioned the word neglect
Keegan, Tilly, Olly and Riley died in the devastating flame last February
The parents Natalie Unitt (26) and her partner Chris Moulton (30) escaped the fire
When the investigation took place, it was found that parents Natalie Unitt and Christopher Moulton had smoked in bed that night. A discarded cigarette is said to have kindled the devastating fire.
The report's author, Joanna Nicolas, said the tragedy had highlighted the need to treat neglect in ways that harm the effects on a child as much as physical or sexual abuse. And she found similarities with several other serious case studies in Staffordshire where "long-term neglect was not well handled".
The Unitt family was first brought to the attention of Staffordshire County Council in 2017. A child protection plan was later put in place, although little progress was made.
The report said: “One of the children's biggest concerns was their lack of language. Experts described the house as silent, although there were five children in it. & # 39;
During an appointment with a pediatrician, one of the teenagers simply grunted and pointed at things. Another had a "frozen expression" in front of a social worker that showed no response.
The children, who also showed signs of developmental delay, were referred for speech and language therapy.
"There is significant evidence that the children were not being stimulated, supervised or instructed adequately," added Ms. Nicolas.
One of them was simply put in her stroller by the television.
Kindergarten staff were also concerned after it was discovered that another child's diaper had not been changed since the previous night.
Over a period of 17 months, the children had more than 50 injuries, spots, or bruises.
Her parents claimed one of the bruises was just play dough, and two other marks were due to bumping into a sofa.
The report commends the efforts of health professionals who tried to get the family to attend appointments.
But Ms. Nicolas said: "The mother controlled the relationships that the whole family had with agencies."
Professionals also failed to realize that Mr. Moulton was the primary caregiver and instead focused on the mother's needs.
However, since none of the parents had “high risk indicators” such as mental health or substance abuse problems, the children were considered at the “low end” of neglect cases. Parenthood assessment plans were "never implemented".
Helen Riley, the director of the Council for Families and Communities, is also the acting chair of the Protection Committee.
She said, "While the tragic nature of these deaths could not be predicted, there are certainly areas of family practice that can be improved."
The tragic death of the children caused grief in Stafford Ward
Ms. Unitt told an investigation last month that she had post-traumatic stress disorder and couldn't remember what she did after the fire broke out.
Mr Moulton, father of three, also testified when examined, saying he believed the fire started on a landing.
Today's investigation found that the children died of "fire fumes caused by a cigarette that was not extinguished" on the bedding in their parents' bedroom.
The Stafford hearing was told that the parents had previously been warned by social workers not to smoke indoors.
Both parents denied that the fire started in the bedroom of the house.
Fire investigator Leigh Richards concluded that the fire in the bedroom was caused by carelessness with cigarettes.
Coroner Andrew Haigh said, “Ms. Unitt has been advised not to smoke on the property, but there is substantial evidence that she continues to do so.
“It is understandable that they have tried to downplay the importance of this undertaking, given what happened.
Moulton suggested that the fire may have been caused where the kettle is on the landing. I don't accept that. I heard the expert evidence and Mr. Richards made it clear why the boiler was not the cause of this fire.
& # 39; He correctly explained his reasons for his decision regarding the cause of the fire. That was that the fire started from a cigarette on the sheets in the master bedroom.
& # 39; Of remarkable importance … in the recess of the left (window) sash there was a single discarded cigarette butt when looking out of the lounge.
“That, in my opinion, hadn't been blunted and had burned itself. In the lounge there were indications of a number of cigarettes scattering the carpet against the baseboards. «
The fire broke through the family's terrace property shortly after 2:40 a.m. on February 2 last year.
Mr. Moulton jumped out the first floor window with his youngest child, then two. Frau Unitt escaped through the front door, said the coroner.
Both parents, who are still together, said they couldn't remember the aftermath of the fire. But Mr Moulton, who was badly burned and in need of a skin graft, believed the fire started on the landing near a cauldron.
Lee Richards, a firefighter with the West Midlands Fire and Rescue Service, said there was no evidence that an electrical fault or a gas supply failure started the fire.
Mr. Richards said the parents' reports were "incompatible" and when he interpreted the scene, the fire started in their bedroom.
He said, “In my opinion the fire developed in the bedroom. As the fire developed, the room went into a full flashover that involved everything in the room in a fire.
"Opening the windows helped ventilate the fire and let the fire grow strongly and spread outside the compartment."
Mr Richards said his investigation revealed "significant numbers of carelessly discarded cigarettes" inside and outside the home.
Firefighters at the site of the fatal house fire that deals with the smoldering house
He said "more than 100 cigarettes" were found outside a door to the garden and "bums thrown under the living room window, bedroom window and undergrowth of the garden".
Mr. Richards added, "Chris and Natalie's actions remain the subject of speculation."
All four children died of smoke and smoke inhaled in the fire.
Staffordshire Police Department Detective Inspector Alan Lyford, who was leading the investigation, told the investigation that the parents had previously received advice "from social workers not to smoke within the home address".
He said he believed that Mr. Moulton, who was the father of three of the children, brought a burning bedspread from the bedroom to the landing to be extinguished.
He said, “After working with Mr. Richards, I agree with him that we believe the fire started in the bedroom. The hypothesis is that a bedspread was moved out of the room which was then set on fire, resulting in Christopher not being able to go down the stairs and gain access to his children.
"It kept Natalie from coming back upstairs, so she had to go down the stairs."
Ms. Unitt said she remembered smoking in bed and fell asleep before she became aware of the fire.
When asked how she became aware of the fire, she said, “I had heaviness on my chest.
& # 39; It was on the landing. I still have nightmares. & # 39;
She denied that their bedding was set on fire or that the couple's bedspreads were pushed down the landing
She said she could not remember the aftermath of the fire because of the post-traumatic stress disorder.
Mr Moulton said he fell asleep in bed after smoking but was woken up by the flame.
When the coroner asked where the fire was, he said, "It was on the landing."
He said he could not save his children because the "fire was too intense".
The Crown Prosecutor's Office said there was insufficient evidence to bring charges against the couple.
Det Insp Lyford told the court: “We gave you an advisory file last December.
"This has been looked into by CPS and they considered several offenses and ultimately found it insufficient to prosecute Natalie or Christopher on the matter."
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