Baby died in Sunderland after multiple failures by social services, review finds
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Version 0 of 1. A vulnerable baby died in Sunderland after being left in the care of her drug-addicted mother following multiple failures by social services, a review has found. The baby, named as Baby A, died in early April 2013 after suffering a heart attack a few weeks after being born. A serious case review (SCR) into the baby’s death – and into the care of one of the baby’s siblings, Child C – found that social workers knew the mother had been taking heroin throughout the pregnancy. She had used the drug, as well as cocaine and cannabis, since she was 16, following the birth of the first of her four children in 1998. The family, who lived in an area of Sunderland with high unemployment, were well known to police, probation, social services and other authorities. “Police visits and raids are a regular aspect of their lives,” the SCR reported. Yet the family’s main point of contact with Sunderland social services was an American social worker, who the report said did not have “an appropriate level of understanding about key procedures”. The social worker told investigators she was used to a more hands-on approach in the US, as opposed to assessment and analysis of facts. The report said: “There was a concerning lack of managerial oversight in children’s social services, which led to drift and delays and a failure to take protective action despite clear indications over a six-year period that the parent was not capable of changing her behaviour to meet the needs of Child C and Baby A.” The mother’s other children had already been taken away from her. Baby A’s father was released from prison in 2011 after serving part of a five-year sentence for dealing heroin. He has six children by three partners. Shortly after leaving prison he and the mother were arrested on suspicion of conspiring to deal class A drugs. None of the family are named in the SCR. As a result of continuing concerns about mother’s substance misuse, Baby A was made subject to a child protection plan and was discharged from hospital into the care of the maternal grandparents in March 2013. The mother, whom the SCR refers to as LB, was supposed to stay with her aunt, who lived near the baby’s grandparents. Yet when Baby A suffered a cardiac arrest at the grandparents’ home, LB was alone in a room with the baby. The SCR notes that the woman’s eldest child “reported coming into the room and seeing Baby A lying over LB’s knee and looking pale” and that “LB appeared drowsy”. The baby suffered brain damage from oxygen deprivation and died in hospital in early April. LB was only supposed to be allowed unsupervised contact with her newborn baby if she passed drugs tests. But no toxicology reports were performed on admission or on discharge. “This did not happen and is a serious omission as LB could have been using drugs whilst in hospital,” said the author of the review. The necessary paperwork for Baby A to be placed with the maternal grandparents had also not been completed, and there was a failure to notify key people and services, including the children’s social services department in the area where Baby A was living, the review found. The family’s main social worker, the American woman, failed to visit the baby at home – a matter of “concern” for the review’s author. She no longer works for Sunderland, a council spokeswoman said. And contrary to community health surveillance guidelines, midwives failed to see the baby every day after the baby was found to have lost 12% of birth weight on day six. “Given mother’s substance misuse, this weight loss could have been an indicator of neonatal abstinence withdrawal and should have alerted the community midwife to potential risks,” the review said. Social services were also criticised for failing to establish the views of Child C, how he coped with his mother’s drug misuse. This was a “significant omission” given “it would be expected that the social worker would have had the child’s ‘wishes and feelings’ and also those of the half-siblings firmly at the centre of the assessment processes”. Police investigated the death, but the Crown Prosecution Service decided in May 2013 that there would be no criminal proceedings. At an inquest a coroner recorded a narrative verdict on the death of Baby A concluding that there was no explanation for the death. Asked whether anyone employed by the council involved in the case ever faced disciplinary procedures, a spokeswoman said: “The report identified a range of practice and process issues which we have taken very seriously. The initial learning from this case has been shared with all those involved.” |