Fatal Accident Inquiry: Council Found at Fault in Death of Robyn Goldie

What the inquiry established

Thirteen-year-old Robyn Goldie died on a summer afternoon in Wishaw while her mother was at the pub. The image is hard to shake, and it has now been followed by an official reckoning: North Lanarkshire Council has been found at fault for failings in child protection measures that should have been in place long before that day.

The case laid bare the abusive environment Robyn endured. In 2020, her mother, Sharon Goldie, pleaded guilty to wilful ill treatment and neglect. The charges captured a grim pattern: failing to provide adequate food, clothing and heating; physically assaulting Robyn; and allowing her to smoke cannabis and drink alcohol. Inside their home, the conditions were squalid—cat urine and faeces left throughout, and a flea infestation that took hold as basic care fell away.

The final hours were set out in court in stark terms. Addressing Goldie, Lord Beckett said: “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.”

Prosecutors accepted Goldie’s not guilty plea to culpable homicide. The court heard she had suffered a serious traumatic brain injury at age nine—an injury that affected her cognition and day-to-day functioning into adulthood. It did not excuse the neglect but provided context for how responsibilities went unmet for years.

After the conviction, a Fatal Accident Inquiry examined what happened and what, if anything, might have prevented it. The sheriff’s determination, now published, reached an uncomfortable conclusion: while services had shortcomings, there were no reasonable precautions that, on the balance of probabilities, would have prevented Robyn’s death on the day she died. No formal recommendations were issued.

That finding does not erase the failings. A serious case review carried out after Robyn’s death—mirroring the inquiry’s core points—highlighted gaps that should never exist around a child at obvious risk. The council has accepted those findings. It says national and local changes have since been introduced to strengthen the way social work, health, schools and police share information, record decisions and escalate concerns.

This is the kind of contradiction the child protection system often produces. A child can be let down over time, yet a court and an inquiry can still conclude that the exact medical outcome on a particular day was not clearly preventable. Both can be true. A fatality inquiry in Scotland isn’t designed to apportion blame; it establishes facts and explores whether practical steps could have avoided the death. In this case, the sheriff found that even if agencies had acted differently, the evidence didn’t meet the threshold to say the outcome would have changed. That does not absolve the system of responsibility for the wider pattern of neglect that went unchecked.

Robyn’s case also exposes how neglect works in real life. It’s rarely a single emergency. It’s gradual—missed appointments, erratic school attendance, evasive explanations, brief periods where things look better, then another slide. Practitioners call this a “drift” risk. Without strong chronologies and confident decision-making, warning signs get scattered across files, emails and conversations. By the time the full picture is assembled, harm can be entrenched.

The council acknowledges that, before Robyn’s death, core practices were not as tight as they should have been. The response since then has focused on basics that make or break child protection: clear records, timely information-sharing, well-documented decisions, and leadership willing to escalate when risk mounts. These aren’t shiny reforms. They’re the plumbing of safeguarding—and when the plumbing fails, everything leaks.

What has changed—and what still needs to work

Council leaders say new systems of work have been adopted nationally and locally. In plain terms, that means aligning with updated Scottish guidance and embedding processes that make it harder for risk to slip through the cracks. While the inquiry made no recommendations, the learning from this case has been folded into everyday practice.

• Stronger record-keeping: Practitioners are expected to keep live, multi-agency chronologies so patterns of neglect and harm aren’t lost in separate files.
• Better information-sharing: Schools, health services, social work and police have clearer routes to share concerns quickly—especially when warning signs repeat.
• Clearer decision trails: Key child protection decisions must be logged with rationale, dates and owners, so progress can be audited and challenged.
• Escalation protocols: When risk remains high or parental engagement stalls, managers are required to escalate promptly to case conferences or legal measures.
• Supervision and challenge: Regular case supervision is designed to test optimistic assumptions and guard against “disguised compliance” by adults.
• Training on neglect: Staff training now focuses more on chronic neglect, not just acute incidents, and on how to respond when home conditions are consistently unsafe.

For families like Robyn’s, these measures matter most in how they play out at the front door. Unannounced visits when concerns escalate. Checks on whether there’s food, heating and clean bedding. Honest conversations with children away from adults. Then, if things don’t change, using legal powers to protect the child. The judgment calls are tough. The system only works if those calls are made early and documented well.

It’s also worth understanding why the inquiry could find no clear precaution to prevent the death yet the council could still be at fault. The legal test in a fatal inquiry is narrow: could a specific, reasonable step, identified from the known facts, have avoided the death on the day? Child protection accountability is broader: did services meet the standards expected to identify and respond to risk over time? In Robyn’s case, the answer to the second question is where the fault lies.

None of this changes what happened on 26 July. The court record is unambiguous: Robyn was in pain that day. She was given a painkiller. Her mother went to the pub. When her mother returned, she and a friend chose to have a drink in the garden. Robyn was found dead an hour later. That sequence will always define this case, however the paperwork is filed.

The inquiry’s determination has now been published, bringing the legal process to a close. The council says it has tightened its practice and aligned with national guidance. There is a simple test for whether those promises matter: when a child shows the same red flags Robyn did—neglect, unsafe home conditions, exposure to drugs and alcohol—does the system spot it, share it, and act on it faster? The answer to that question will tell us if anything truly changed.