Changes needed after death of four-week-old Norfolk baby - report

Following the death of a four-week-old baby changes are needed to protect children from neglect, a safeguarding review has found.

It is thought the baby's mother, who had been drinking and smoking cannabis, may have rolled on her while asleep.

Maternal neglect had previously been raised concerning the baby's siblings.

Norfolk Safeguarding Children Partnership (NSCP) said it was acting on the safeguarding review recommendations.

A criminal investigation ended with no further action taken.

The baby, known as AK, was the youngest of five children - the others being two boys and two girls all under the age of 14.

The report said the children all had different fathers who did not live with the family, but had been "been variously involved in caring for the children".

One of the boys was profoundly deaf, while one of the girls had significant learning needs.

The safeguarding review made multiple recommendations, including recognising the increased risk to babies born into larger sibling groups, and the use in complex cases of existing guidance to help inform multi-agency decision making.

However it noted that even if all changes had been implemented there was no guarantee the baby would have lived.

'Chronic low-level neglect'

A review of harm into her siblings may not have happened without her death, the report noted.

The review found it had been "widely acknowledged" that children in the family "have a history of adverse life experiences attributable to chronic low-level neglect".

The report said there was a pattern of agencies only responding to "incidents of acute concern".

Intervention by Norfolk County Council's Children's Services often categorised the parenting as "not quite good enough, but not quite bad enough" for a higher threshold of intervention, the report found.

Risks were not assessed relating to the changing context and family dynamics, the review found.

Risks 'not fully recognised'

It also found there had been an absence of a joint multi-agency understanding and approach to the family and "little agreement" about how to respond to neglect.

Recommendations also included the production of good practice guides by the NSCP for working with fathers and father figures.

Professionals working with expectant parents should be mindful of current and historical substance misuse and the impact on children, the report recommended.

Chris Robson, independent chairman of the NSCP, said: "It is clear from this review that, despite extensive support from multiple professionals, there wasn't full recognition of the impact and risks that neglect posed to AK and her siblings."

This was a national issue, he said, adding more was needed to help professionals "better recognise the signs and effects of neglect".

He said the partnership was acting on the recommendations.

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