Warning signs missed by authorities in heartbreaking death of four-week-old baby in Northamptonshire, report finds

A four-week-old baby died in Northamptonshire four days after a safeguarding plan was “stepped down” and before a safeguarding report from paramedics was shared with the relevant authorities, a report has found.

The Northamptonshire Safeguarding Children Partnership has published a report looking into the case of the baby - who is referred to as Child Ba. The baby died in June 2020 as a result of a co-sleeping incident with their mother.

Detailed in the report, written by independent author Dr Russell Wate, professionals suspect Child Ba died “as a result of having been overlaid by their mother”. The report also found that the mother was “intoxicated through alcohol and had taken cocaine”.

Alcohol misuse

At the time of the death, the mother and Child Ba were staying with a friend of the mother after she left her parent’s house after they raised concerns about her drinking.

On the night of the death, the mother and her friend consumed five litres of alcohol between them, the report states. The mother went to bed with the baby in a double bed.

The report says: “Mother woke up in the morning and discovered Child Ba in the bed purple in the face and not breathing. They had marks on face, chest and knee which suggested they had been laid on.”

Following the incident, the mother was arrested on suspicion of neglect and gave a blood sample that revealed at the time of Child Ba's death the level of alcohol would have been 194mg per 100ml of blood. The driving limit is 35mg.

Safeguarding concerns

Prior to the fatal incident, and even prior to birth, there were safeguarding concerns primarily relating to violent domestic violence from Child Ba's father, who was in prison for the entirety of the baby’s life.

The report adds: “Four months prior to their birth, Child Ba, was placed on a Child Protection Plan due to these concerns. This was under the category of neglect.

“Due to the mother's progress whilst living with Child Ba’s maternal grandmother, the case was stepped down to Child in Need (CIN) at a Child Protection Conference review.

“The Child in Need plan was closed at a meeting at the beginning of June 2020, which was four days before the death of Child Ba.”

“Hindsight bias in reviews can feature in reports, but in this case, there does appear to have been more than sufficient grounds for maintaining the Child in Need plan rather than deciding to close it,” the report adds.

The report goes on to say that although the domestic abuse that the safeguarding plan centred around was an “important factor”, the plan overlooked a number of other factors including: alcohol abuse, neglect of an unborn child, historic involvement with children’s services, housing issues, smoking, mental health and missing healthcare appointments.

The report adds that the mother had been known to Children’s Services since 2012, including a number of incidents where there were concerns about the safety of her other children.

Dr Wate adds: “There was an impact of over optimism by professionals, particularly with the step-down process and closure, but there are several comments raised in the information recorded by professionals throughout Child Ba’s case that do not provide assurance that risks to child Ba had been mitigated.

“What there isn’t provided for in meetings was if there was actually any evidence to support that there had been any positive changes? This only relied on what the mother self-reported as positive.”

Delayed report

Furthermore, in May 2020, East Midlands Ambulance Service attended a call relating to the child’s grandfather. Child Ba was also present and paramedics noted that the mother had been drinking and when asked about it she became “verbally abusive”. Medics also noted that the child had an “unsafe sleeping environment” as the “Moses basket had a pillow placed over it.

Police were not called, but a safeguarding concern was generated. However, the report found that this concern was not shared with the relevant partners until after Child Ba’s death.

The pandemic

Another contributing factor that the report mentions is Covid-19. As the birth and death of the baby happened during the pandemic lockdown, the report also says that Covid-19 had an impact on the situation.

Dr Wate writes: “There is no doubt that Covid-19 had an impact in this case, firstly it allowed the mother to avoid any face-to-face contact or intrusive involvement in the home.

“Secondly, the step-down process was carried out less rigorously due to Covid-19 restrictions.”

Conclusion

In conclusion, the author said there are three main learning points to take from the report, which are: professionals needing to assess the impact of parental behaviour on the state of the child more robustly and the need for professionals to have a deeper understanding of the impact of parental alcohol misuse on children. The third is unsafe sleeping arrangements.

The report concludes: “Unsafe sleeping has been a factor in a number of recent child deaths in Northamptonshire, this has triggered a separate review of a refresh to current practice in relation to advice and support given to expectant and new parents around safe sleeping and how this can be further strengthened.

“A further repeated theme running through this review into the death of Child Ba is that practitioners focused too much on the needs of the mother and overlooked the implications for her child and their lived experience.”

Four recommendations were made to NSCP, which included ensuring all professionals have a better understanding of the impact of parental alcohol misuse on children, the re-launch of the county’s Safer Sleeping campaign, checking that step down procedures are working “robustly and rigorously” and considering what needs to be put in place to support grandparents, and family members, who they expect to act as a protective factor to parental risks to safeguarding children.

Read the full report here.