A serious case review examining the circumstances surrounding the death of an 18-week-old baby has been published jointly by the Northamptonshire and Milton Keynes Safeguarding Children Boards today (Wednesday).
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.
Until his death, Child M had been seen by a number of health and children’s social care professionals who described him as a happy, healthy baby.
The serious case review has considered whether there is any learning for the agencies involved in this case and as a result has 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 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 cover report for the serious case review can be found at www.northamptonshirescb.org.uk and at www.mkscb.org.