Experts rule lessons can be learned from the tragic death of a five-month-old baby boy, found next to his drug-taking mum in Milton Keynes

The lengthy review published by the Milton Keynes Safeguarding Board refers to the child as Baby J, and describes him as a "placid, contented and alert baby who liked being cuddled".

It reveals how his mum, dad and three siblings had been known to city social services, police and health officials for two years before he was born.

And it describes how the mum, who had a history of crack cocaine addiction, had previously had a child removed by social services. Also on official records were concerns about drug-taking and reports of domestic violence.

The review, which was completed last month - more than three years after the baby's death, states: "The parents had lived in Milton Keynes when they were children. Both had unstable childhoods and a history of substance misuse. Mother’s first child was removed from her care as a toddler, due to neglect, and was subsequently adopted.

"During their relationship Father spent a lot of time in Mother’s household, but also maintained a separate address. The relationship during the period under review was characterised by instability, including domestic abuse, frequent house moves, and a period abroad."

But the review report adds that Baby J's siblings, who were all under the age of six, "appeared to be loved" and were engaging and boisterous.

"The family did not stand out in any particular way in the local community where they lived," it states..

But in March 2017, Baby J was taken to the hospital in the early hours of the morning after he was found unresponsive by his maternal grandmother on a bed where his where his mother and the other siblings were sleeping. Sadly, he was declared dead.

"A crack pipe was found in the house. Mother’s urine proved positive for both cannabis and cocaine. Maternal Grandmother refused to be interviewed by the police. A subsequent hair test for Father, used as evidence during the care proceedings, proved positive for cannabis," states the report.

An inquest later recorded a narrative conclusion, saying the cause of the baby's death was ‘unascertained’.

But the tragedy immediately sparked a Child Protection investigation and the three siblings were taken into care.

The review details a number of warning signs that all was not well with the family before Baby J's death. These include a visit from health visitor who noticed, "but apparently did not challenge", a strong smell of cannabis in the house, and a midwife detecting that the mum "smelt strongly of cannabis" during a pregnancy appointment.

"The midwife gathered further information from Children’s Social Care and the health visitor and decided to offer additional support from the Red Team due to the historical concerns and domestic abuse incidents. Mother refused this support," states the report.

It reveals how police had visited the family five times before Baby J's death and information was shared with Children’s Social Care about three of the incidents.

"Two involved arguments between family members/alleged violence by Father toward Mother. The third involved children being found alone in a messy house. Father returned and stated he had been outside the house, in the parking bay."

The fourth incidents involved an altercation between three women at the house and the fifth was a call from the mum requesting a “violent man” be removed from her house.

"She was heard to ask the siblings 'what did daddy do to mummy’s throat?'" states the report. It adds: " The police risk assessors in MASH (Multi-Agency Safeguarding Hub) did not review the report for two weeks due to backlogs of incidents caused by a staff shortage."

Police even arrested the father on one occasion - for being the tenant of a warehouse where a “cannabis factory” was found.

"Officers did not include this information in the referral they subsequently made to Children’s Social Care about the messy house," says the report.

A nursery attended by one of the siblings reported to MASH concerns about the child's aggressive behaviour and "unkempt" appearance, while also noting the father's concerns about the mum's mental health.

Meanwhile, a social worker from the MASH team made an unannounced home visit.

"The social worker thought he smelt cannabis; Mother said she “did not do drugs anymore”. The social worker concluded that the family were going through a difficult time due to the separation. He felt Mother would benefit from some support, which she declined. The social worker concluded a Child and Family Assessment would be appropriate if there were any further concerns," states the report.

At the beginning of December 2017, when Baby J was only a couple of months old, there was a serious fire at the house.

"Mother was advised to take Child J to the hospital as a precaution," states the report. "Mother’s initial behaviour within the Accident & Emergency Department appeared appropriate. However, as time passed, her behaviour became increasingly bizarre and erratic, alternating between pacing and agitation to periods of calm and with no attempts to address her dishevelled appearance, as attendees in her circumstances would usually do. Accident & Accident staff thought her behaviour and bizarre comments, (eg. ghosts starting the fire and her phone typing on its own), could be indicative of a post-natal psychotic episode and made a referral to the Mental Health Services."

The report adds: "A number of agencies contacted MASH Multi-Agency Safeguarding Hub as a result of the fire. The social worker assisted the family to get temporarily re-housed and offered Child and Family Practice (CFP) for practical help. The parents declined this."

Shortly afterwards, during the early weeks of 2017 there were three reports to the police alleging domestic abuse of the mum by the dad. All these were shared with Children’s Social Care and a 'Signs of Safety mapping meeting' was convened. But the subsequent 'Team Around the Family' (TAF) meeting was cancelled by Mother.

It soon became clear that, despite attempts at providing a co-ordinated service, the mum was continuing not to accept offers of routine health checks and additional support, states the report.

"In addition, there were concerns about the on-off relationship with Father, Mother making and then retracting allegations of domestic abuse, and the lack of understanding by both parents of the impact on the children of all the arguments, the going back and forth between properties and not attending school regularly."

A further Team Around the Family meeting was planned to pull together all the information so a referral could be made to Children’s Social Care.

But this never happened because, tragically, it was superseded by Baby J’s death.

The safeguarding board agreed to undertake its review using the Significant Incident Learning Process, a "learning model" that engages frontline staff and their managers to focus on why those involved acted as they did.

It has now published a lengthy "conclusion of lessons learned."

These include the fact that practitioners need to be aware of the potential risks to children’s health and wellbeing associated with parental drug use, including when adults are arrested for drugs offences, and be able to describe and record the potential and actual impact clearly.

"Parents who misuse drugs can be very plausible, and agencies had different pieces of the jigsaw relating to suspicions of substance misuse which would have benefited from being analysed as a theme," states the report.

"No tangible evidence of crack use was ever found until after Child J died. After Child J’s death Mother admitted that she was using crack cocaine for a minimum of five months prior to his death."

The review also recommends more awareness among professionals of the impact of domestic violence on children, stating: "The number of incidents of reported domestic abuse, or neighbour disputes where the children were present, should have prompted some consideration of what it would feel like to live in such an environment."

For members of multi agency teams, there should be "a relentless focus" on the impact on children, it states.

"Practitioners should ask themselves in every contact: “what is life like for this child”, “is it good enough”, “what might their presentation and behaviour tell us about their experiences, wellbeing and emotional health”?"

But the case review concluded that overall, even if all these measures had been followed, there would have been no way of predicting the tragic outcome for Baby J.

"Whilst more scepticism about what practitioners were being told might have been useful on occasion, the parents were skilled at deception and it is difficult to take action when there is limited tangible evidence... Whilst there are a number of learning points from this review which will be useful to improve services for children and families in Milton Keynes, there was also considerable evidence of good practice in this case from all agencies."

Examples of this good practice have been highlighted by the review as: attempts to build relationships with the parents, professional curiosity and tenacity, prompt responses and thorough assessments, information sharing, partnership working, and escalation.