More on KentOnline
Nearly two years after their bodies were discovered the tragic deaths of a mother and her toddler daughter remain a mystery.
Ugandan-born Lillian Oluk and two-year-old Lynne Mutumba were found at their home at Trafalgar Court, Trafalgar Street, Gillingham, a week after last being seen alive.
A serious case review, which has just been published, has pieced together the mother’s fractured life since she came to the UK to study in 2009 up to the days before they died in March 2016.
While some shortcomings have been identified by the panel, there were no concerns for their health or welfare.
There was no indication from the various agencies and professionals that either were at risk of significant harm or death.
On the morning of March 14, a representative from a Croydon-based housing provider went to check the property, but received no reply.
On the instruction of her manager she returned 30 minutes later and this time let herself in with a spare key.
She knocked on the slightly ajar bedroom door noticing Ms Oluk’s foot on the floor, but assumed she was asleep.
The alarm was raised when she went back again at 5.30pm and saw that she was lying in the same position and was unresponsive.
Paramedics were called and discovered the body of the little girl.
The panel raised concerns that after registering with a GP in Medway in January 2016 she was not allocated a health visitor.
Lead reviewer Fergus Smith said: “This apparent oversight represents the most significant missed opportunity to have more effectively supported mother and daughter.”
When Ms Oluk arrived in this country she initially lived with her half sister in Croydon.
But when her visa ran out, an application to remain was refused and in October 2011 she became an “over stayer”.
The following years saw her moving to several addresses in the Croydon area.
At one point, she became homeless and the immigration service placed her in Wolvehampton before she was transferred to Gillingham in December 2015.
Mr Smith wrote: “The need to transfer the family from Wolverhampton to Medway was unfortunate but the financial costs and practical consequences of the move were picked up by Immigration and Asylum Support Service.”
Between December and March, mother and child attended prayer meetings, church and local shops.
But closer to the time of their deaths, Ms Oluk stopped buying food regularly which could imply “shutting down” and giving up.
On the other hand it was noted she sought a top-up on her gas card, suggesting forward planning.
After their deaths, contact was made with their limited family, including Lynne’s father who did not respond.
On meeting the mother’s half-sister Mr Smith wrote in his report: “This individual, her husband and their family have been deeply affected by the loss of Lynne and her mother.
“They remain as puzzled as the professional network, including medical experts, about the circumstances and causes of the deaths of mother and child.”
Post-mortem examinations failed to find a cause and a coroner at an inquest recorded an open verdict.
Medway Safeguarding Children Board (MSCB) carried out the review.
Its independent chairman John Drew said: “On behalf of the board, I would like to express our sincere condolences to the family.
“As the child and her mother were housed on behalf of Croydon Council, the review has already been shared.
“Following the review, improvements to multi-agency co-operation have already been made.
“We have discussed the recommendations in the report with Croydon Council’s Immigration and Asylum Seekers’ Service, who have strengthened commissioning arrangements to ensure all providers are aware of their safeguarding responsibilities.
“New GP registration arrangements have also been put in place to ensure the details of children arriving from outside of Medway are shared with health visitors and school nurses.”