The failure of the authorities in assessing the risks posed by a man who went on to kill his baby boy 'probably' contributed to the child's death, an inquest heard.

Alfie Gildea was four-months-old when his father, Sam Gildea, inflicted fatal injuries on him while his mother Caitlin McMichael was away from the house after going to the doctors.

Sam Gildea was previously jailed for 19 years after admitting manslaughter by committing an 'act of deliberate and unlawful violence which involved rigorous and violent shaking'.

Now a coroner has ruled that GMP and Trafford council did not 'effectively assess' the risk posed, or 'communicate' that level of risk to Ms McMichael.

She told the inquest she only learned Gildea had a previous history of domestic violence after Alfie's death.

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Gildea, described as a 'serious and serial domestic abuse perpetrator', was known to GMP and had a history of committing domestic abuse.

Officers did not identify that Ms McMichael was in a controlling and coercive relationship and did not consider whether Clare's Law could have been used.

Coroner Alison Mutch said: "The failure by the three agencies, GMP, Children's Services and the Health Visitor Service, to effectively assess the level of risk posed, to communicate that level of risk to his mother and to recognise that his mother was in a coercive and controlling relationship probably contributed to Alfie's death."

GMP and Trafford council said they accept the coroner's findings and have made changes.

Alfie was attacked by his father on September 12, 2018, and died in hospital two days later.

The previous month police had been called to the family home, in Partington, Trafford, after Gildea, who did not have a driving licence, took Miss McMichael's car without permission.

Caitlin McMichael

The coroner said officers had treated it as an incident of 'taking without consent of a motor vehicle' rather than as 'behaviour consistent with a coercive and controlling relationship'.

Ms McMichael told the inquest how she lost touch with her friends as Gildea became more controlling.

Officers did not 'explore fully' what she knew about the 'previous history of domestic abuse'.

Children's services and the Health visitor team were notified of the incident but did not appreciate the risk to Ms McMichael.

There had been another incident of domestic abuse, in July 2018, but opportunities were missed and the Crown Prosecution Service later decided to take no further action.

GMP alerted Children's services but it 'failed to review all the material' and the case was closed 'without effective communication with other agencies'.

The coroner said the Health visitor service 'did not effectively engage with Alfie's mother'.

A psychiatrist had previously assessed Sam Gildea as suffering from split personality disorder, and advised he would benefit from further support.

But the psychiatrist was unaware of the history of allegations of domestic abuse because 'incomplete information' had been provided by GMP.

Alfie Gildea was only four months old when he died at the hands of his father

Gildea's diagnosis was not shared with the Health visitor service.

He was referred and had been due to attend an appointment on September 11, 2018, which was cancelled to due to staff absence.

The appointment was rescheduled for a day later, when Alfie would die at the hands of his father.

The coroner ruled that Alfie had been unlawfully killed, and died as a result of a head injury.

Describing her son, Ms McMichael said: "He was smiley and giggly, he was always really happy, he always had a smile on his face".

After the inquest, GMP said: "The death of Alfie Gildea was a tragedy and we continue to offer our deepest sympathies to his mum and wider family, who have all suffered unimaginable pain since his heart-breaking death.

"We respect today's findings and the views of the coroner.

"Since Alfie's death in September 2018, we have reviewed our safeguarding strategies and revised our force domestic abuse policy.

"We have already implemented changes, with a greater focus on partnership working.

"We recognise that reports of domestic abuse are often extremely complex and must involve the expertise of specialists from partner agencies from the very outset in order to provide the best support possible.

"This multi-agency approach is something that is reinforced in all training.

"We ensure that cases such as this one are reviewed at the highest level to take as much learning as possible to continue to safeguard the public to the very best of our ability.

"It will always be our priority to safeguard victims and any potential victims from the risk of domestic violence.

"We will now take some time to consider the detailed remarks of the coroner and await her final report; so that we can consider what further procedural changes can be made to ensure that opportunities such as this are not missed in the future."

A spokesperson for Trafford Council said: "We would like to extend our deepest sympathies to Miss Caitlin McMichael and her family following the tragic death of her son.

"Following Alfie’s death, a Serious Case review was immediately launched to look into the circumstances and see what lessons could be learned.

"The coroner has noted the significant changes that we have made since then to Children’s Social Care, as well as recognising our open and honest submissions to her.

"We accept the findings made by the coroner and we will continue to strive to protect all victims of domestic abuse."

Elizabeth Jenkins, deputy chief crown prosecutor for CPS North West, said: " Tackling domestic abuse is one of our key priorities and we remain fully committed to providing the highest standards in our decision making. 

"We accept the finding of Her Majesty’s Coroner in this case. 

"In the course of evidence to the inquest we acknowledged that the decision taken by the prosecutor in July 2018 was below the required standard and that an action plan asking the police to undertake further reasonable lines of enquiry would have been an appropriate next step. 

"Since that decision in July 2018 both CPS North West and CPS Direct have delivered training to strengthen decision making in this difficult area. 

"We would like to extend our deepest condolences to Ms McMichael on the loss of her son, Alfie.”

Pennine Care NHS Foundation Trust, which runs the Health Visitors Service, was contacted for a comment