A four-week-old girl from Northamptonshire who was found dead in her parents’ bed had suffered neglect through most of her short life, a serious case review has found today.
The baby, who is referred to as Maisie Harrison in the report - although that is not her real name - died of suspected sudden infant death syndrome (SID), in May 2012, and the review her death could have been caused by co-sleeping.
She was found on a mattress in the flat of her parents - an 18-year-old woman, who is called ‘Natalie’ in the report, and a man in his thirties with the pseudonym ‘Karl’ - which was littered with drug paraphernalia.
The report found “insufficient curiosity” in some professionals involved in Maisie’s Child Protection Plan, and her plan was not properly followed, but stressed that even proper interventions may not have saved Maisie’s life.
However Kevin Crompton, the independent chair of Northamptonshire’s Local Safeguarding Children Board, said better sharing of information between agencies would have ensured Maisie would have had a better life while she lived.
He said: “Whilst we can take some optimism from certain aspects of the case and the work of some of the professionals, the overall position is that we failed to protect this child by allowing her to remain in conditions that represented a risk to her safety.
“There were serious failures in practice, which should not happen. I urge every professional in the county involved with safeguarding to read this report and reflect on whether it would have happened on their shift.
“We need to get better and be smarter when it comes to parents with these sorts of risk in their profile.
“We need to properly risk assess and in a timely manner and we need to seriously ask ourselves whether we should allow children to live in the conditions described in this report.”
One of the most worrying elements of the review was that Maisie’s father had been imprisoned in 2001 for assaulting his six-year-old step-son, leaving him with “serious internal injuries”.
This was flagged up by Northamptonshire County Council’s Adult and Children’s Services department and a child protection enquiry was undertaken.
But, although Maisie was forbidden from staying with her father, the report uncovered that social workers visited the baby at his flat and did not alert anyone.
Mr Crompton said: “A social worker was trusting of a view that Maisie was just popping round to dad’s flat on that occasion and that certainly seems to have been the case.
“It just happens that when the social worker went, she wasn’t at mum’s and they said ‘we are taking her back later’.”
Mr Crompton said that right from when Maisie was allowed home, social workers were too trusting of her parents, not carrying out unannounced visits and not ensuring she was living at her grandparents’ home as per the protection plan.
He said: “One of the things I do find difficult is that the plan required the child to be at the grandparents’.
“But she was taken from the hospital after she was born by the social worker and allowed to go to the parents’ flat whilst they were ‘getting some things together’ then they’d ‘go round to the grandparents’’ and that was taken on trust. And it shouldn’t have been.”
A week-and-a-half before Maisie died, she was visited by a new social worker, who noted the baby was growing well but that her parents wanted permission to move to her father’s flat.
However, the report found no further social services visit took place and Maisie died 10 days later.
Mr Crompton said: “I have no reasons given in the report for that and that will be down to the social work management team to take that issue forward and find out.
“It could be anything from work rota, inability to gain access and so on but what social workers have to do in those circumstances is persevere. So it’s a serious breach of duty and I presume that was dealt with by the social care department.
“Given that most social services are short-staffed I suspect there will be issues like that. But I‘m independent and I’m looking at it and thinking there can’t be an excuse, can there? The visit should have been made and procedures have to be in place to make sure proper practice is followed.”