The death of a Derbyshire baby in a family with historic alcohol, sexual and substance abuse and neglect issues was “neither predictable nor preventable”, a hearing has concluded.
A Child Practice Review into the death of the baby girl – who was less than three months old – has only now been made public.
The girl, referred to as Child C to maintain her anonymity, died in 2018.
A post mortem examination found that the baby, one of five half siblings, died from sudden infant death syndrome (SIDS).
A report published by the board says that the mother had a habit of sharing her double bed with the baby – despite consistent warnings over the dangers it presents.
The report says that the family in question had historic involvement with local authorities over the past 15 years and had, at the time, only recently moved to Derbyshire.
The oldest child of the mother was the subject of care orders with another local authority after suffering abuse at the hands of her step-father – for which he was convicted.
It is said that the family has a “complex history involving alcohol and substance abuse, sexual abuse and neglect”.
Local authorities had concerns about the “mother’s ability to adequately protect her children,” the report says.
They had been told by the mother, that she had not used substances or drunk alcohol for 14 years.
At the time of the baby’s death, a case was awaiting assessment by Derbyshire County Council’s children’s services department following an incident involving the family just a week before.
This incident had been referred to the council by East Midlands Ambulance Service (EMAS).
A week before the baby’s death, ambulance staff were called to the house by the mother in the early hours of the morning.
The baby had been dropped from a height of roughly 4.5 feet after being passed between intoxicated adults – including the mother – who had returned from a late night party, the report says.
Ambulance staff referred the case to children’s services due to the time of night, the intoxication of the adults, the fact that the children were still present during the incident and that the adults were having consistent arguments.
EMAS has been praised by the board for its quick actions in correctly noting safeguarding concerns during the incident.
Fortunately, after being taken to a hospital under the remit of Nottingham University Hospitals NHS Trust, it was found that the baby had not suffered any injuries.
Following the baby’s death, a pathologist said that the incident the week before – in which the baby was dropped – had not contributed to the girl’s death.
The review found that in the 12 months before the death of the baby, while the mother was 17 weeks pregnant, her eldest daughter had threatened to push her down the stairs.
After this, the child grabbed a kitchen knife and allegedly tried to stab her mother.
This case was referred to children’s services by the mother, and the child was moved back to her placement out of the family home.
However, the review found that “no consideration was given to Child C or the mother’s potential capacity to care for another child” following this incident.
The police told the board during the review that in 2014 they were contacted with reports that the mum’s children had been sent to the pub late at night by their babysitter to “look for their mother”.
The board said in its report: “There is a need for timelier responses in cases involving potential injuries to pre-mobile babies where there is concern about potential neglect and concerning adult behaviour.
“Immediate sharing of information could have led to a more robust and timelier response.
“The baby’s potential vulnerability could have been more robustly investigated.”
The mother, who had a history of substance abuse, had been prescribed with tramadol and codeine (both addictive painkillers) at the time of the baby’s death, for an ankle injury.
She said that this often made her feel drowsy, the report said.
On the day the baby died, she had been fed at between 3am and 5am and had shared her mother’s double bed.
The mother had woken up at 11am and proceeded to head downstairs to make a phone call and have a cup of coffee – she did not check on the child, the report says.
When she came back upstairs to check on the baby, she found that Child C was not breathing and called 999 at 11.59am.
On arrival, ambulance staff found a male giving CPR to the baby, but found that she was “cold to the touch with no signs of life and recognised Child C as life extinct”.
The board said that “no samples in relation to drugs or alcohol were taken from any of the adults in the house” during the police’s investigation.
It also says that police were not initially aware of the incident in which the baby was dropped the week before its death – highlighting what it thought was a lack of rapid communication between agencies.
The board also said that it had struggled to gain the input of the mother during its review.
It suggested that the situation was “complicated” due to the time of the review coming around the anniversary of the baby’s death, and the birth of another baby.
The board found that little was known by the authorities about the father of Child C – the mother’s new partner – including his potential history of offences and parenting of other children.
The review concluded that “the death of Baby C from SIDS was neither predictable nor preventable.
“There was in fact significant evidence of good practice in this case but equally, learning – although having no impact on this case overall – could improve practice in relation to future cases where there is a potential or actual injury to a pre-mobile baby.”
A Derbyshire County Council spokesperson said: “The council fully participated in this Child Practice Review and accepts the findings. The baby’s cause of death was Sudden Infant Death Syndrome and is a tragic loss for the family.
“While the death was not connected to any practice issues, reviews of this nature which examine the practice of all agencies in detail are useful for the examination of potential learning.
“We continually work to strengthen our child safeguarding practice and procedures and use every opportunity to learn and develop.
“Actions arising from the review will be overseen by the Derbyshire Safeguarding Children Board.”
A Derbyshire Safeguarding Children Board spokesperson said: “The board considered and accepted the recommendations in the report and a practitioner conference on the general issues took place in May 2019.
“Training events are now reinforcing good practice in relation to pre-birth and bruising on babies and a publicity campaign to raise awareness is being planned for later this year. The board will review the impact of these measures during 2020.”