Kasukabe city didn't act on a hospital's request for a prompt home visit to a high-risk family, and the baby was killed days after the city's first visit, a prefectural review found.

The Saitama Prefecture serious child-abuse case review committee, in a report posted 31 March 2025, found that Kasukabe city knew of several risk factors when the mother registered her pregnancy but did not refer the family to the local child-protection council, which had no criteria for taking such cases. After the baby's very premature birth in May 2021, the city made no organisational review of its support plan and left the response to one public-health nurse; it received a hospital's form asking for a home visit within a month, but after the mother said on the phone that things 'seemed' fine, it made no home visit until mid-September, about two weeks after the baby came home from a roughly four-month hospital stay.