Robyn Goldie died on 26 July 2018 from peritonitis caused by a perforated duodenal ulcer. Her mother, Sharron Goldie, left her at home unwell while she went to the pub. Goldie, 49, was jailed for three years and six months in 2020 after admitting neglecting and ill-treating her daughter over a 12-month period.

The inquiry at Hamilton Sheriff Court concluded that Robyn’s death might have been avoided if her mother had sought medical help. Sheriff Linda Nicholson said: “Had that precaution been taken, it might realistically have resulted in the death being avoided.”

The sheriff found no defects in systems of work that directly contributed to the death. However, she determined that North Lanarkshire Council had failed to comply with its own policies and procedures. There had been no written comprehensive assessment or child’s plan, and social workers were inadequately supervised. Child protection measures and referral to the Scottish Children’s Reporter Administration should have been made earlier, she said.

“I conclude that there was systemic failure on the part of social work to the extent of failure to comply with policy and procedures in Robyn’s case. That included not only the lack of a written comprehensive assessment and child’s plan but also a lack of supervision. However, the evidence did not support that the systemic failure contributed to Robyn’s death.”

The determination noted that the council has since implemented new systems to address the shortcomings.

A spokesperson said: “The death of Robyn Goldie was a tragedy. The sheriff found that Robyn’s death could have been prevented by her mother seeking appropriate medical assistance. Robyn’s mother was convicted of neglect and ill-treatment at the High Court in 2020. However, the sheriff also found that some of the systems of work used by the council were not effective or fully complied with, and some decisions about Robyn’s case could have been taken earlier.”

The court previously heard that Goldie subjected her daughter to neglect by failing to provide adequate food, clothing or heating, striking her, allowing her to drink alcohol and smoke cannabis, and exposing her to unhygienic conditions including cat urine and faeces. Prosecutors accepted her plea of not guilty to culpable homicide.

In sentencing, Lord Beckett told her: “Your daughter was in pain that afternoon, you gave her a painkiller and went to the pub. By the time you came home she was slumped on the sofa but you and your friend went into the garden to have a drink because the weather was nice. She was dead an hour later.”