A review into the death of a toddler in Pembrokeshire, murdered by her stepfather has found there were missed opportunities to protect her.

Two-year-old Lola James died in hospital four days after a “sustained and very violent attack” by Kyle Bevan in the early hours of July 17, 2020 at her home in Haverfordwest.

Bevan, 31, of Aberystwyth, was later found guilty of Lola’s murder, and was jailed for life, with a minimum of 28 years.

Lola’s mother Sinead James, 30, of Neyland, was found guilty of allowing the toddler’s death, and was sentenced to six years in prison.

Lola suffered 101 separate injuries including a ‘catastrophic’ brain injury.

Bevan had claimed Lola had fallen down the stairs, but was found guilty of murder.

A child practice review, commissioned by Mid and West Wales Safeguarding Children Board, has now published its findings, including that an assessment of Lola's needs was "not properly undertaken" prior to her death.

The review found that an assessment of Lola carried out by Pembrokeshire County Council's children's services on 10 February 2020 was "lacking in detail and analysis".

The report also found the assessment had not been completed by the named social worker, who was absent from work at the time.

"The consequence of what happened in this case is that an assessment of child A's needs was not properly undertaken by children's services, as required," the review concluded.

The review found "the service was overstretched and morale was low", but notes the situation was "far more positive" as of June 2024.

The review also raised "a number of missed opportunities by the health visiting service".

This includes the conclusion that the health visitor "could and should have made arrangements for a home visit" after a telephone call with James on 8 June 2020.

James failed to agree to any home visits in the five-month period between 15 February 2020 and 16 July 2020.

"In future cases, far more probing and challenge is needed by health visitors," the review found.

The local authority's immediate internal review into Lola's death "did not identify a number of issues regarding the assessment process".

The independent review also concluded it was "disappointing" that information-sharing between multiple agencies continued to feature as a factor in reports like this one.

“It is impossible to say what would have happened had the above information been shared between the police, social services and the health visitor or had the dots been joined at the relevant times,” stated part of the report.

“However, sharing information and acting upon such information is an intrinsic part of any frontline practitioners’ job when working with children. The decisions about how much information to share, with whom and when, can have a profound impact on the lives of those needing protection.

“Additionally, information sharing helps to ensure that an individual receives the right services at the right time and prevents a need from becoming more acute and difficult to meet.

“It is an obvious learning point that practitioners must ensure that information is shared between agencies, that agencies very clearly understand when they are able to legally do so, and for agencies to “join the dots” when they have relevant information.”

Following the report, the Local Authority’s Cabinet Member for Social Care and Safeguarding Cllr Tessa Hodgson said: “Pembrokeshire County Council would first like to convey their sincerest condolences to the family of Lola James and to all those who have been affected by her murder, over four years ago.

“This review process, that we have fully and openly engaged with along with our multi-agency partners with whom we share safeguarding responsibilities, has been an opportunity for the local authority to reflect on its practice and to learn from the observations contained in the independent report.

“We would like to recognise the significant commitment and input of those who have taken part in the review process, and who have been involved with the family over the last four years.

“The local authority takes extremely seriously its duties within the safeguarding arena, and places the protection and support of the most vulnerable in society as its key priority.

“Whilst we would always strive to demonstrate good practice, there is always room for improvement and the opportunities that this review has presented us with, will allow us to improve how we work with vulnerable children and young people in the future.

“Ahead of the publication of the report, we had developed an action plan to deal with the issues the review has raised for us, and we have made considerable progress against that plan already.

“In addition, we have established a social care improvement board, which includes amongst its membership locally elected politicians, senior officers and an external independent expert. This board will oversee delivery against the actions within that plan, with progress also being reported into local authority scrutiny committees and cabinet meetings.

“We hope also that the report, will contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities in the West Wales region and beyond. It is imperative that we take all opportunities to improve our services, and ensure that children and families receive the best quality of support available.

“Once again, Pembrokeshire County Council would like to extend its deepest sympathies to the family and all of those who knew Lola,” she added.

PCC, Hywel Dda University Health Board and Dyfed Powys Police made the following joint statement to accompany publication of the report: “All agencies involved in this report wish to convey their sincerest condolences to the child’s family and to all those who have been affected by the murder of a child in such appalling circumstances.

“This review has been an opportunity to reflect and share learning amongst all partner organisations and practitioners on a multi-agency basis, and we acknowledge the commitment and contribution of those who have taken part in the review process.

“All agencies take very seriously the opportunities that this review presents, to consider our practice and improve how we protect vulnerable children. We hope that the report will also contribute to wider ongoing learning and improvement in relation to a number of key safeguarding issues across all agencies with safeguarding responsibilities.”

The Mid and West Wales Regional Safeguarding Board will oversee the delivery of an action plan to ensure lessons continue to be learnt and that services are improved across all agencies.

Following publication of the report, Carl Harris, Assistant Director at NSPCC Cymru, said: “Lola deserved a happy and healthy future, but that was cruelly taken away by the horrendous actions of Kyle Bevan and the failure of her mother, Sinead James, to intervene.

“The findings in this report highlight yet again the need for greater investment in children’s services in Wales to provide comprehensive support to any child at risk of harm and to be better equipped to prevent a tragedy such as this happening again.

“It is time to make child protection a national priority. The Welsh Government has committed to transforming children’s social care, but we need to see more details on timescales, activity and progress.

“We need systemic changes that ensure children like Lola are better protected.”