A damning report into the death of a nine-week-old baby from co-sleeping with his Northampton mother has criticised professionals for not spotting signs of neglect in the family.
The Northamptonshire Safeguarding Children Board (NSCB) has today published the findings of an investigation following the death of a baby who had been sleeping with his mother on the sofa.
The nine-week-old, referred to as ‘child R’, died on December 20, 2014, when his mother awoke to find her baby unresponsive.
An open verdict was recorded at an inquest in October.
But the death prompted a Serious Case Review, which looked at the actions of how a number of organisations including Northamptonshire County Council and the NHS interacted with the child’s family.
And at a press conference this morning, Keith Makin, chair of the NSCB board, criticised a “failure of leadership.”
The report states health and social care workers - and the primary school attended by the Child R’s siblings - missed “a number of incidents that may have indicated neglect”.
A spokesman for the NSCB, said: “These included family siblings attending school wearing dirty, damp clothing, been seen picking up food to eat off the dining room floor and a very serious case of both older children of head lice infestation.”
The report finds that at no point during the period under review, did any organisation, including the school, use the online Northamptonshire Neglect Assessment Tool - the system for reporting suspected neglect in the county.
The report author said this indicated an “absence of awareness of its existence or a lack of professional curiosity about the need to assess whether the children were suffering neglect”.
Child R was born following a second “concealed” pregnancy at home, the report says.
The mother was given advice by midwifery and visiting health staff from Northamptonshire Healthcare NHS Foundation Trust about the dangers of co-sleeping, alcohol consumption and smoking - a habit which continued after the birth of all the children, the report adds.
But the review found there was a serious failure by professionals to engage with her.
Chair of the NSCB , Keith Makin, said: “This was a very tragic case and it is clear from the review that no single agency could have prevented the death of this baby boy.
“It is also apparent the death could not be linked to neglect.
“However it has raised important issues on a number of fronts including failure by professionals to properly engage with the mother, whose two concealed pregnancies should have been viewed as a safeguarding concern.”
Mr Makin said steps have already been taken to address the issues raised and the Safer Sleeping awareness campaign was launched in January by the NSCB.
There will also be a requirement for all professionals to use the Northamptonshire Neglect assessment tool in all cases of neglect.
The report also calls for a review of training given to schools, to ensure teachers know how to spot signs of child neglect.
It states that states all professional agencies should be fully conversant with the guidance on concealed pregnancies.
And it states awareness should be raised among health, education and social care professionals of the damaging effects to children’s emotional wellbeing when suffering with persistent lice infestation.
A Northamptonshire County Council spokesman said: “This is a very tragic case and as a result we have worked with our health partners and other agencies to raise awareness of issues around concealed pregnancies and the dangers of co-sleeping.
“In terms of the siblings, at the point when concerns about the children were reported to us, there was nothing to suggest that our involvement was needed at that stage. Unfortunately, we weren’t involved later on when intervention may have been needed for the welfare of the siblings.”
“We welcome the findings of the serious case review into this tragic accident.
A spokeswoman for NHS Northamptonshire Healthcare said: “Since this accident 15 months ago, we have joined with other local organisations to launch a safe sleeping campaign. We would like to take this opportunity to remind parents that the safest place for their baby to sleep is on their back in their own cot or Moses basket whether this at night or in the daytime. Health Visitors will routinely offer advice about safe sleeping and discuss the risk of co-sleeping with parents.
“As a Trust we have signed up to the countywide neglect strategy and we are ensuring that all our staff are aware of the toolkit. We are working in partnership with GP colleagues to ensure that parents are supported to make the right choices in relation to immunisation of their child. We have developed a new health information sheet on the management of head lice which we are in the process finalising before sharing with schools and parents.
“We are pleased to see highlighted in the report the good work of our student health visitor in getting this family to reengage with some services. We have a good programme for student health visitors and all students receive safeguarding training.
“We are committed to ensuring every child is protected and every child receives the best possible start in life.”