A series of lapses in the reporting of abuse and follow-up checks contributed to the death of four-year-old Megan Khung, who was physically and emotionally abused for more than a year.
During that period, she was forced to wear soiled diapers over her head, eat food from the dustbin, and eat her mother's mucus. She died in 2020 after a fatal punch to the stomach, and her mother and her ex-boyfriend burned her body to hide their crime.
Teachers at the young girl's pre-school, Healthy Start Child Development Centre (HSCDC), had observed visible injuries on her in March 2019.
The centre, which is run by social service agency Beyond Social Services, submitted a report to the Early Childhood Development Agency (ECDA) in early April 2019.
The ECDA is the regulatory authority for pre-schools here.
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"However, the report did not fully describe the severity of the injuries. This resulted in inadequate interventions by the relevant agencies," said the Ministry of Social and Family Development (MSF) in a statement on April 8.
Megan's mother, Foo Li Ping, was sentenced to 19 years' jail on April 3. Foo's then boyfriend, Wong Shi Xiang, 38, was sentenced to 30 years' jail and 17 strokes of the cane.
MSF said that Beyond did not escalate the case to the ministry's Child Protective Service (CPS), which manages high-risk child abuse cases, and has the powers to remove a child from their family to keep the child safe.
In response to queries from The Straits Times, MSF said the report indicated that Beyond Social Services had established a care plan for Megan, and that her mother agreed to have Megan move in with her grandmother.
The report concluded that Megan appeared happy, had no further injuries, and had been attending pre-school daily.
"Based on the information presented by HSCDC, there was no reason for ECDA to suspect child abuse," MSF said.
The pre-school and social service agency should have used the screening and reporting guides relating to child abuse management, the ministry said.
"If they had done so, they would have recognised that the injuries were significant, reported the injuries accurately as suspected intrafamilial child abuse and consulted ECDA or CPS urgently," it added.
The school and agency should have reported more decisively to CPS but it did not, said MSF.
In a statement on April 8, Beyond Social Services said that the care plan they established for Megan to put her under her grandmother's care was intended to ensure her immediate safety with regular check-ins, while working with her family toward a longer-term caregiving arrangement.
After Megan was withdrawn from pre-school in September 2019, Beyond Social Services consulted a Child Protection Specialist Centre, a community agency which manages the low to moderate risk child abuse cases, as they were still concerned about Megan and her whereabouts.
The Child Protection Specialist Centre advised the Beyond community worker to continue working with Megan's grandmother to check on the girl's well-being in person.
A month later in October, the Beyond community worker wrote to ECDA again to inform them of Megan's withdrawal from their pre-school, and said they had contacted the Child Protection Specialist Centre about Megan's case.
The Beyond staff also asked ECDA if Megan was registered in any other pre-school.
ECDA did not find records of Megan's enrolment in other pre-schools, and advised the Beyond staff to lodge a police report if there were concerns about the girl's whereabouts. Megan died four months later in February 2020.
Megan's father, Mr Khung Wei Nan, 37, a businessman and content creator known as simonboy, later made a police report in July 2020 as he was worried about her safety and whereabouts.
Beyond Social Services said it endeavoured to safeguard Megan's well-being by adhering to its operating procedures at the time.
The organisation said it has taken steps to strengthen its ability to better detect and respond to complex or high-risk situations since 2020, including those where signs of abuse may not be immediately evident.
"The staff involved in Megan's care have carried the emotional weight of this tragedy for the past five years. We respectfully request privacy for our staff as they continue their healing process," said Beyond.
"We remain focused on doing our part to address the gaps that this tragedy has brought to light, and on ensuring that when red flags emerge, however subtle, they are recognised early, and escalated swiftly and clearly across all relevant agencies."
Steps taken to boost child protection system
Over the last 10 years, there were at least eight cases that were not known to social services when the child was killed, the MSF said in its statement. ST has asked MSF for more details about these eight children.
"Each death reminds us we still have some way to go, in our protection systems, and as a society," MSF said.
"With each case, we learn what was missed, and strengthen our systems, processes, practices, and policies so that we can prevent more deaths," it added.
Protocols on how pre-schools should handle suspected abuse cases were enhanced in 2021, after the death of Megan.
Educators and pre-school staff are required to report suspected child abuse to ECDA, and they are trained to recognise signs of child abuse or neglect.
In 2021, guidelines were added to better guide pre-schools on the actions to take if a child is suspected to be a victim of abuse. They are required to assess the situation and report any child abuse concerns to ECDA within 24 hours.
If there are concerns about sexual abuse, noticeable injuries, or signs of immediate threat to the child's safety, pre-schools are required to consult the National Anti-Violence and Sexual Harassment Helpline within two hours.
They are also required to document visible injuries on the child on a diagram, instead of just a written description.
If a child with child abuse concerns has been regularly absent or is withdrawn from pre-school without valid reasons, pre-schools are required to inform the social worker or MSF's Child Protection Officer working with the child. This was not required before 2021.
If the child is not known to any social service agency or CPS, pre-schools must report the matter to ECDA, which will then assess whether a report to CPS is necessary. said MSF.
The ministry has also reviewed and tightened the operating processes between ECDA and CPS. Since 2021, when there is a claim that a case has been raised to CPS or a Child Protection Specialist Centre (CPSC), ECDA is required to verify the information with CPS to ensure that the case receives appropriate follow-up.
System-wide enhancements and the push for better detection of harm to children have saved other lives, MSF said.
"But we have also lost others, and these should starkly remind all of us in the field that there is more work to be done."
Another young girl, Umaisyah, was 2½ years old when she died in 2014.
Her parents abused her often - hitting her with a belt and hanger, slapping her, and flicking her lips. On the day of her tragic death in March 2014, Umaisyah's parents slapped her across the face a few times as they were upset she was playing with a soiled diaper.
Umaisyah bled from the mouth, collapsed and gasped for air. Her father's assault caused significant traumatic brain injury, and led to a concussive seizure.
After she died, her parents burned her body and hid it in a pot for more than five years. When asked about Umaisyah's whereabouts in the years before her remains were discovered, they lied to family members that she was being cared for by a relative in Melaka or that she had returned to her foster parents.
MSF said a key lesson from past child abuse cases over the last decade is that intervention is often hindered when parents deny access to their children or give false information about their whereabouts.
In a framework introduced in 2020, social service agencies follow specific procedures when they have trouble sighting or locating a child. If they cannot find or see the child, and there are concerns about the child's safety, the agency must report it to the Police immediately.
"Every case of abuse is one case too many. The MSF is deeply saddened by cases where children suffered abuse at the hands of trusted ones who should have kept them safe."
"This includes the tragic death of Megan Khung. The senseless harm caused to these children is nothing short of a tragedy. No child should ever endure harm at the hands of those who are supposed to love them the most."
