An investigation into the death of an 18-week-old baby that led to the mother being convicted of manslaughter has made a number of recommendations to local authorities.
In a report released today by the Northamptonshire and Milton Keynes Safeguarding Children Boards, it was revealed that the child had been seen by a number of health and children’s social care professionals who had described the baby as “happy and healthy”.
The baby, referred to as Child M in the serious case review, died in hospital in March 2014 after his mother called 999 to report that he was unresponsive and struggling to breathe. Child M’s mother was subsequently convicted of manslaughter.
The court heard she had previously suffered from mental health problems and had been suffering from severe post-natal depression.
The serious case review considered whether there was any learning for the agencies involved in this case and as a result issued the following recommendations:
• To create a clear and multi-agency pathway of support for parents with perinatal mental health issues
• To develop a specialist perinatal and infant mental health service with dedicated staff
• To use safeguarding training to re-emphasise the need for timely multi-agency strategy meetings following incidents of unexplained injuries of this type.
A spokesman said: “A number of the agencies involved in Child M’s case have already reviewed their processes as a result of this case. Confidential communication between midwives and health visitors has been improved, a new complex cases team has been introduced in maternity services and mental health training for maternity staff has been revised.”
Keith Makin, independent chairman of the Northamptonshire Safeguarding Children Board, said: “This is a very tragic case and the Northamptonshire and Milton Keynes Safeguarding Children Boards have worked together with the key agencies involved to establish what lessons can be learned.
“We have already supported agencies to introduce a number of actions, including improved communication between midwives, health visitors and mental health teams, and a review of mental health training for maternity staff.
“This serious case review has highlighted a number of areas where practice can continue to be developed to increase the chances that families in these circumstances might be more likely to access effective support in the future and we will now ensure that the recommendations of the review are implemented.”
Jane Held, independent chairman for the Milton Keynes Safeguarding Children Board, said: “This is a sad case for everyone involved. The serious case review has highlighted the importance of recognising and responding to perinatal mental health concerns quickly and effectively and of helping families to recognise their need for professional support.
“The review has identified a number of areas where practice can be developed to increase the chances that families in the same circumstances might be more likely to access effective support in the future.”
The Serious Case Review report concluded that it was “difficult to know whether any individual agency could have prevented the death of Child M, even if additional support had been offered.”
The report states: “Better communication and collaboration would have given agencies a clearer perspective on mother’s needs, and allowed for a more effective package of support to be offered.
“However, professionals are ultimately reliant on parents agreeing to take up the support available. It is clear that mother and father were reluctant to access support, and once the family had left hospital after Child M’s birth there were no indicators that mother’s mental health concerns were sufficiently severe to warrant a safeguarding assessment or mandated intervention of any kind.”
The report found that Child M’s mother and father both seemed “keen to downplay the degree to which mother was struggling with her mental health.”
It states: “On occasion she would open up to professionals (usually at points of crisis, and when father was not present), but would soon shut down these conversations and declare that things were ‘fine’. Undoubtedly they had their own reasons for doing so – perhaps related to stigma or shame, or to simply preferring to manage as a private family unit”