Death of three-month baby sparks safeguarding review

“Emma” was found unconscious after being propped up with inappropriate bedding in her pram in May 2020. Her tragic loss sparked a review by the Hartlepool and Stockton Safeguarding Children Partnership (HSSCP) to see whether the authorities had done enough – or if there were problems in the system uncovered in the case.

The report found officials had relied too much on Emma’s mother’s ability to parent, and manage a partner who posed a risk having committed a sexual offence in the past. The probe also uncovered a lack of professional curiosity in the mother’s relationships.

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There were also missed opportunities to spot signs of neglect in the case – and officials urged better explanation and help when it came to helping families ensure babies slept safely. 

Emma died in early May 2020 after she was found unconscious by one of her siblings. 

Paramedics and police who arrived at the scene flagged up neglect issues.

Blankets and a cushion in the pram were covered in mould and not suitable for a child to be sleeping in. Emergency staff described the home being in a chaotic state with “faeces and nappies strewn around” and “loose tablets on the floor”. 

The cot in the home had also been unused with Emma propped up in a pram. Examinations into the baby’s sad death ruled out any non-accidental injuries – and suspected the cause was asphyxia with pressure marks around her neck and chin from Emma falling forward. 

The report also explained how the doctor had found some signs of neglect upon examination with animal hairs under her arms and in her fingers, dirt on skin, and severe nappy rash. Investigations also looked at the years preceding the tragedy to understand the family circumstances – and where agencies had contact with Emma’s mother and her other children. 

Timeline

A rapid review was held in June 2020 to look into what had happened – with a child safeguarding practice review triggered afterwards. These processes are designed to improve the welfare of children both on Teesside and nationally – with wider important implications for people working with children as well as for the government and those steering policies. 

They also aim to understand whether there are problems in the system – and whether practices need to change.  The detailed probe showed the history of Emma’s mum and some of the circumstances she’d endured. 

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Emma’s mum was a looked after child who was first pregnant at 16. Social care teams had been involved with the family in the past – with her first child put up for adoption 12 years ago. Neglect concerns were raised in 2013 relating to her second child – and the report showed how she had three other children to care for alongside Emma. 

Two of the children had health needs to care for. Social care teams returned to the family in 2018 after a new partner of the mother – Emma’s dad – arrived with an historical sexual abuse offence to his name. But the report revealed how a child protection plan had been “stepped down” at the time of Emma’s death. 

Professionals raised worries about a “history of neglectful parenting, drug use and sex work”. There were also a number of domestic abuse incidents between Emma’s mother and father with the relationship eventually ending. 

String of concerns

Details of events between 2018 and Emma’s passing were also retold. Concerns about the health and education of her mother’s children were shared in 2018 and 2019.

One of the mother’s children was noted as very overweight in March 2019 while in April that year, primary school officials spoke to her about the hygiene of one of the youngsters – with questions about his dirty fingernails. In June 2019, officials recorded a positive assessment of the mother’s ability to protect her children given the father was not to have unsupervised contact with them. 

Pregnancy came in the second half of 2019 – but health officials noted how the mother was “smoking 10 to 15 cigarettes a day” in November. Once again, primary school staff noted dirty fingernails of one of the children in October, and an attendance tag for two of the siblings being missing from school was flagged that month. 

One of the children suffered a radiator burn in November where a follow up appointment was missed by the mother.A third case of dirty fingernails was flagged up by the school in December – with their concerns about hygiene and attendance also raised in a meeting. 

Emma was born premature at 33 weeks in late January and spent 11 days in a special baby care unit. Maternity staff said the flat the family had moved to the previous October was “not appropriate” – before Emma and her mother were discharged into the father’s home with one of Emma’s siblings. 

But the following day the police were called by Emma’s maternal grandmother with concerns Emma’s mum was being held against her will by her father at his house. A verbal altercation between the couple followed where it emerged he was having a relationship with another woman. 

Over the next month, the children’s school attendance fell again. And Emma suffered a number of health troubles during her short life. 

Health worries 

The report showed how her mum had attended hospital with her on March 7 after she’d stopped breathing eight hours before. Emma’s grandmother had performed “rescue breaths” to help the baby start breathing again.

Hospital officials told social care teams about this episode as they were worried Emma’s mum may have delayed seeking medical help. Another domestic abuse incident followed four days later – leading to Emma’s mum moving into sanctuary housing. 

But Emma’s health didn’t improve as March wore on – with the report showing she suffered bronchitis and pneumonia. April arrived with worries about Emma’s siblings being exposed to domestic abuse incidents as well as more concerns about hygiene and children missing medical appointments. 

On the 15th, a call between Emma’s mum and a social worker dug into what had happened when Emma stopped breathing on March 7 – with Emma’s mum “remorseful” and admitting she was under strain from a relationship breakdown. April 24 saw a health visitor arrive at the family home – with no concerns about Emma’s wellbeing or the conditions in the property flagged up during the pre-planned visit. 

Emma’s mum reported her mum was supporting her which was helping her anxiety in late April. Another police visit came on April 30 in response to domestic abuse concerns between the mother and father – but no worries were flagged about the children or the home’s condition. 

Three days before Emma died, a pest control officer removed a rat trap from an infestation outside – and the pest controller noticed the flat was dirty, smelt and had hygiene issues in the kitchen. The final entry in the summary timeline showed how Emma’s mum had had regularly propped her up in her pram overnight.

Shortcomings and what to do to put it right 

The report found how the string of incidents in the family brought stress, anxiety and trauma – with house moves, covid, relationship troubles, the needs of the children, housing and the mother’s mental health all flagged as vulnerabilities. Overcrowding in the homes and the mother’s long term use of Tramadol were also flagged as important. 

The report added: “In the weeks leading up to Emma’s tragic death, Mother had to care for four children with little support, with Emma and Sibling 3 hospitalised with chest infections and a change of home address.Taken together with the fact that covid ‘lockdown’ had begun and the family were being stepped down to early help, these stresses were not noticed by professionals.

“The aggregated cumulative factors appear to have led to a decline in Mother’s ability to cope with the demands of looking after four very young children each of whom had health and learning needs. It is clear that life would have been uncomfortable, unsafe and possibly traumatic for the children given these circumstances.”

The investigations found there were a number of key missed opportunities before Emma’s death – naming the incident where she had stopped breathing, and where she had been admitted with pneumonia and bronchitis later that month. The probe found the responses to school absences and missed health appointments weren’t shared among agencies. 

Examination of Emma’s passing found a health visitor was aware of one of the children sleeping in her mother’s bed but the “impression given to her was that Emma was in the cot”. The report added: “There are no records to indicate that Emma was propped up during visits and at the learning event the health visitor confirmed that safe sleep had been promoted.”

Conclusions 

The review urged a number of improvements including better communication, more “professional curiosity” by workers, and understanding the underlying trauma parents – the mother in this case – had faced. Focus on the father’s sex offence “meant partners were not as alert to indicators of neglect” in the case.

A decision to step down the case was also “overly optimistic” – with agencies unable to track significant changes in conditions at a key point in Emma’s life as there were “minimal” visits and checks. Rounding off, the review was unable to establish why living conditions in Emma’s home appeared to change dramatically in her final days. 

The report added: “Whilst the conditions were not the direct cause of her death, they were indicative of a mother who was struggling to cope and who was not therefore meeting Emma’s needs and ensuring that she was in a safe sleeping position.Mother’s own childhood experiences of trauma and abuse, coupled with substance misuse and her relationships with MGM (maternal grandmother) and Father had a significant impact upon her ability to care for Emma and three other children.”

Trauma was not addressed and information “was not shared” when it came to the build up of risks and neglect. The review added: “There were a number of incidents over the preceding few months that cumulatively increased need and risk, and could have been predicted. 

“At such a critical point partners had reduced multi-agency oversight and closed the case. The timing of this decision meant that partners were unable to recognise this rapid decline.”

Emma’s mother believed how she’d placed her was the correct way for her to sleep – yet professionals, including those who had shared safe sleeping advice with her, were unaware Emma was being propped up. 

The HSSCP has been contacted for comment on the improvements made and lessons learnt since Emma’s passing. 

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