Could the tragic deaths of a pregnant mother and her three young children have been prevented?

The bodies of Levina, three, Addy, two, and Kyden, 11 months, were found at their home in London Road South, Kirkley, hours after their mother Fiona Anderson fell to her death from a multi-storey car park on April 15 last year.Miss Anderson was seven months pregnant with her fourth child at the time of her death - a daughter who she had named Evalie Brianna.

A serious case review, conducted following the deaths and published today by the Suffolk Local Safeguarding Children Board (LSCB), revealed that the Anderson family had been known to a variety of child care agencies from the time of Miss Anderson’s first pregnancy in mid-2009.

The report identifies that Suffolk County Council Children and Young People Services (CYPS) first started working with Miss Anderson and the children’s father Craig Mclelland prior to the birth of Levina amid concerns about their parenting abilities.

It states that all three children were the subject of child protection plans at the time of their deaths, which identified concerns about possible physical and emotional neglect.

During their more than four year involvement with the family, social workers visited them numerous times amid fears about the children’s wellbeing, in particular their low weight and lack of stimulation.

However, the child protection plans they put in place had little effect as both Miss Anderson and Mr Mclelland refused to engage with them.

The parents repeatedly missed the appointments designed to help them and, although repeated issues were raised by several agencies, formal action was never progressed to place the children in care.

On one occasion, at the end of May 2011, there were concerns that Levina and her brother Addy were being neglected following claims that the children had been sleeping in a double pushchair for 13 nights and had only been fed biscuits.

The case was closed following a CYPS assessment as Miss Anderson had agreed to engage with the local children’s centre.

Less than two months later, police were called to a domestic abuse incident at the family’s home. Officers reported that the children looked malnourished and very tired and had full nappies. They said there were bits of bread lying on the floor and only a large carton of milk in the fridge and a dry loaf of bread.

The family was visited by a social worker and a family support worker from a children’s centre, when Levina and Addy were witnessed to be in play pens for long periods with little stimulation and both silent.

The support of the nursery was offered but refused by Miss Anderson.The report raised concerns about staffing and found that a student social worker was allocated the first key role of working with the family while care proceedings relating to Levina were being instigated in 2009. It said someone with greater knowledge and experience was needed to handle the complex case and it was “a most inappropriate decision in the circumstances”.

An unannounced Ofsted inspection of CYPS in July 2010 identified that child protection plans were “carried out by unqualified staff or staff who are not yet registered as social workers” in the area where the family lived.

An internal review at the time confirmed the findings and identified that “many of the managers had a fatalistic view of working in Lowestoft, and that as the furthest away from county hall, resources were tight and other areas were better staff.”

However, this view was not supported by the evidence, which showed Lowestoft compared favourably with staffing in other areas.

Legal intervention to secure the safety of the children was considered towards the end of 2011 but this was never taken forward and was “allowed to drift” for more than a year without further action.

There were no substantial changes to the child protection plans during 2012, important assessments did not take place and a summary of concerns was not sent to the legal department as expected.

The need for Miss Anderson to have a psychological assessment was also raised during 2012 but this was never progressed.

Little changed during 2013 and it remained difficult to progress the child protection plans. Crucially, plans to hold a legal strategy meeting as a matter of urgency did not materialise.

Despite this, the report author Ron Lock concluded that the death could not have been predicted.

He said: “There had been no known history of either the mother or the father intentionally causing physical harm to the children, or of any self-harming episodes by the parents themselves. In this respect, the deaths of the children and their mother were completely unexpected. It was not predictable or thought in any way likely.”

The report, which identifies 13 learning points, was discussed at an extraordinary meeting of the LSCB last month.

Following the meeting, Peter Worobec, independent chair of the LSCB, said: “The board fully accepts the important lessons from this review and I would want to stress that things have and will continue to change as a direct result of this tragedy.

“In our response to this review, 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.

“In addition we have identified a further 21 actions that will be taken to ensure that practice is improved, it has the desired impact and is embedded across the county and in all agencies.”