Crisis hit Croydon children’s services failed little Kyrell Matthews in the months before his murder, a review has found.

Police, social workers and other agencies all missed chances to intervene in the abuse of the two-year-old little boy before his violent death at the hands of his mum Phylesia Shirley and her violent ex partner Kemar Brown.

The review reveals that Brown, who was found guilty of murdering Kyrell, had been assessed by the Probation Service as a ‘high risk of harm to the public, to rival gang members and to previous or future partners.”

After the jury reached its verdict Croydon Safeguarding Children Partnership published its review of the case, setting out in detail the last few months of the little boy’s short life. 

On several occasions, it found, police and social workers and other agencies missed chances to intervene.

A major opportunity was missed in May 2019 when Kyrell, then aged 20 months, was taken to hospital with a serious head injury.

Shirley, 24, who was found guilty of her son’s manslaughter told hospital staff that it was caused when Kyrell jumped from a sofa on to the metal edge of a highchair and that she had witnessed this and that her partner was in the kitchen. 

While clinicians assessed it as ‘more likely’ accidental, they had doubts and Croydon social services agreed to make a home visit to check up on Kyrell after his discharge. 

A nurse had noted that the injuries were extensive for a fall, that mother was in a new relationship with an unknown male and that even if accidental, the injury should raise concerns regarding lack of supervision as Kyrell was described as ‘highly active’. 

Children’s social care described the injury to Kyrell’s face  as ‘considerable’ but once Kyrell was back at home  social services cancelled the visit because it was not a priority. The review notes showed that  a senior manager in children’s social care reviewed and overturned the decision because “the threshold for a referral had not been met”. 

Social workers dismissed the hospital safeguarding team’s concerns as “professional anxiety”. This was a mistake, the review said, but it was made, it noted, “in a bigger systems context”.

Croydon’s safeguarding system was slowly emerging from being “inadequate” and was more crisis-led and seeking to accept only the highest priority referrals. 

The review said: “To close the case without informing the hospital was a mistake as this would have led to further dialogue about the hospital’s concerns.”

Croydon children’s services had been labelled ‘inadequate’   in a devastating inspection by Ofsted two years previously. 

There had been some signs of progress by the time of Kyrell’s death, but it was still dogged by high staff turnover, lack of clarity over safeguarding thresholds, and a “legacy of drift”. 

Shirley’s pregnancy was unplanned and she  had separated from Kyrell’s father but he had frequent contact with his son and when permitted by Shirley the little boy visited his paternal grandmother’s home. 

The review team had met with Kyrell’s father  who described how he was ‘angry and very worried’ about his son when he saw the injury to his head and face which he felt was not taken seriously. He believed that social care should have been involved and was not aware that the hospital had, in fact, referred their concern about the injury to social care. 

The review revealed that Shirley had received a lot of help from the authorities over the years.  Family support services lined up for this vulnerable single mother with a history of trauma and depression which included historic domestic abuse and alleged serious sexual assault as a child.

But she would agree to professional help, then ignore it and her parenting was chaotic and inconsistent. She regularly missed GP appointments for Kyrell including for immunisations and went for months without seeing a health visitor.

In July, the police were called to a domestic dispute at her home after a passerby heard Shirley shouting, “Stop hitting my face.” No action was taken after Shirley denied she had been assaulted. The police also failed to notify children’s services; had they done so, police records would have revealed that her new partner was Brown, a man with convictions for assault, possession of weapons and domestic abuse.

Croydon has high levels of domestic violence and notes the review: “The police did not complete a routine notification to Children’s Services which would have been expected operational procedure after such a domestic incident.”

The police visit, the review, found, was a missed opportunity, as well as the last time Kyrell was seen by any professional. Three months later he was killed. 

Brown, also had a child who he was in  regular contact with,  was well known to police from 2006 for offences of robbery assault, burglary, affray, possessing weapons, possessing cannabis, breaching bars conditions and domestic abuse.

A month before Kyrell’s murder Brown had told his probation officer that he was in a new relationship and says the review : “this should have been explored more fully so that relevant checks would be undertaken, given his history and known risk to prospective partners .”

Shirley and Brown who were unemployed at the time of Kyrell’s death, were cannabis users. Brown had told his probation officers that he smoked cannabis twice per day and that he did not see cannabis misuse as either a problem or illegal.

The review concludes that the police call out in July 2019 when Brown was identified was not shared with Children’s Services, as it should have been, and given information about Brown would probably have led to a Child and Family Assessment and would have identified ‘potential risk’ to Kyrell.

The review which made eight recommendations  makes no mention of Shirley’s employment at Croydon Council where she had worked in Children’s Services or her second pregnancy.

Debbie Jones, chair of Croydon Safeguarding Children Partnership (CSCP) said:“This was the brutal murder of a very young child. The two people who were supposed to care for and protect him – his mother and her partner – were responsible for his death. As a partnership, we are devastated by his loss and our deepest sympathies are with his family.”

“Kyrell’s tragic death highlights the extreme vulnerability of very young children, who are able to be kept hidden from view. Kyrell’s mother received good support during his early infancy, but when he grew older, he did not attend nursery or pre-school, and was often not brought for routine GP appointments. For many months, Kyrell did not come into contact with professionals who might have noted concerns.”

“However, there were some opportunities to identify risks to Kyrell, and to be more assertive in engaging and challenging those who were entrusted with his care. We very much regret that these were not taken, and we have made changes to the way we work as a partnership to ensure that together, we do everything in our power we can to protect children like Kyrell.”

You can download the full report here: