Logan went to hospital with a broken arm and bruises but was not referred to child protection.
Hospital doctors failed to share with child protection services a list of “significant” injuries a five-year-old boy suffered 11 months before he was murdered, a case review has found.
Logan Mwangi had a broken arm and multiple bruises across his body when he was taken to A&E in August 2020.
But a paediatric consultant said these injuries were accidental and did not make a child protection referral.
Logan, from Bridgend, was murdered by his mother, stepfather and a teenager.
Logan’s mother, Angharad Williamson, 31, is now serving at least 28 years in jail for the murder in July 2021.
His stepfather John Cole, 40, will serve at least 29 years in prison and Craig Mulligan, 14, was given a sentence of at least 15 years.
A Child Practice Review (CPR) has looked at how different agencies were involved with Logan’s family in the 17 months before his death.
It has recommended that Cwm Taf Morgannwg health board commission an independent review into how it identifies and investigates non-accidental injuries.
The report said that if the injuries had been shared with social services, appropriate action could have been taken to safeguard Logan.
On 16 August 2020, Logan was taken to A&E after a fall down the stairs, which his mother described as accidental.
31 images of other ‘significant injuries’
A&E made a referral to Bridgend children’s services to report that there was a delay in Logan being taken to hospital after the fall.
However, while Logan was in hospital a further assessment was made and a paediatric doctor took 31 images of other “significant” injuries which included bruising to his forehead, ears, cheeks, arm and a carpet bruise on his chin.
The review said some health staff were “uncomfortable” about the decisions around Logan but felt unable to express their concerns.
It added that there was a culture in the health board where staff were reluctant to challenge decisions made by more qualified professionals.
The paediatric consultant did not consider Logan to be a child “who had sustained a non-accidental injury” and there was no evidence that information about the injuries was shared with agencies outside the health board.
The review makes 10 recommendations as part of “significant core learning,” to be carried out locally by the health board and local authority and five more which need to be brought in Wales-wide.
It follows an August 2021 report that raised “serious concerns” about children’s services in Bridgend.
In that report, Care Inspectorate Wales (CIW) said “urgent action” was needed but noted some improvements had been made since an inspection four months earlier
‘Complicated and complex’
This latest review, commissioned by Cwm Taf Morgannwg Safeguarding Board, praises the police for their response and also the role played by Logan’s school.
It also said the initial child protection report by social services was an “accurate and concise assessment” of the risks and needs of Logan and his family, despite being a “complicated and complex task to achieve.”
Logan died after Williamson, Cole and Mulligan subjected him to a “brutal and sustained” attack, leaving him with 56 injuries, including tears in his liver and bowel.
Cole and Mulligan then dumped his body in the River Ogmore, just 250m (820ft) from his home in the Sarn area of Bridgend.
‘Nothing short of horrifying’
Police officers found Logan partially submerged in the river wearing his dinosaur pyjama bottoms and a Spider-Man top.
Mrs Justice Jefford said the attack was “nothing short of horrifying”.
Mulligan was not related to any of them, but Cole had raised him since he was nine months old and considered himself a father figure.
The review details the complicated background of family relationships, in which Cole and Williamson lived at points in a polyamorous relationship with another long-term partner of Cole, the mother of Mulligan.
The case is also set against the background of the Covid-19 pandemic, which had a significant impact on working practices, as well as Covid being used by the family as a barrier to engage with services.
This also led to an absence of one-to-one sessions with Logan outside the family home, partly due to restrictions and partly due to pressures from staff absence in social services due to Covid.
Its recommendations include a focus on sharing information between agencies within Cwm Taf Morgannwg’s safeguarding hub and raising awareness on how the public can raise concerns about potential abuse and signs of coercive control.
The review also said Logan’s family circumstances had “complex dynamics”, and the family courts in future should consider 12-week minimum periods to give more time for social worker assessments, when in this case they were given only four weeks.
Timeline of events leading to Logan’s murder
August 16, 2020: Logan is taken to hospital by Williamson. She suspected he dislocated his shoulder when he fell down the stairs the day before. Doctors find Logan has broken arm and make a referral to social services.
January 21, 2021: Williamson calls 101 and during the conversation tells the operator Mulligan had confessed to pushing Logan down the stairs when he fractured his arm.
March 16: Logan placed on child protection register which means social workers have to visit every 10 days.
June: Social workers in Bridgend remove Logan and his younger sibling from the child protection register as he was no longer considered to be at significant risk of harm. He was still considered to be a child in need.
July 21: Logan tests positive for Covid-19 and has to self-isolate.
July 26: Family Court approve Cole and Williamson’s custody application for Mulligan, who moves in with them five days before Logan’s murder.
July 29/30: Logan is seriously assaulted. The accounts of Williamson, Cole and Mulligan vary.
July 30: Mulligan’s social worker Deborah Williams visits the flat but is denied entry as Logan has Covid-19. She stays for 20 minutes and leaves without seeing or hearing Logan.
July 31: CCTV shows Cole and Mulligan dumping Logan’s body in the River Ogmore at 02:43.