A three-month-old Derbyshire baby boy died after being accidentally suffocated by his sleeping mother.
The incident, which happened in 2015, has now lead to a call for council officials, including those in Derbyshire early help service, to improve how they spot signs of neglect.
The call has come from the Derbyshire Safeguarding Children Board, which also wants more awareness to be raised around safe sleeping.
Details of the baby boy’s identity are not being made available due to “confidentiality”, the safeguarding board has said.
A summary of the incident has been published with the aim of local authorities learning vital lessons.
In the lead up to the fatal case, it had become known that the mother and baby had been sleeping downstairs and that “the mum did not always wake up during the night when the baby cried, due to being a heavy sleeper”.
The summary criticises Derbyshire County Council’s multi-agency team for missing opportunities to take action. A multi-agency team is a group formed from health, education and social workers at the council.
The baby involved lived with his mother and two older half siblings.
No male adult lived in the household or was involved with the care of any of the children.
The county council’s children’s services team had been involved with the family previously, “predominantly for neglect”, said the summary.
That team remained in contact with the family in the months leading up to to the birth of the baby due to fears over the oldest half sibling’s behaviour.
But, despite being in contact, they were still not aware of the pregnancy.
That only became known to local authorities after a visit by the police to the house, prompted by an anonymous phone call about the “alleged poor state of the premises”.
Police made a referral to the county’s children’s social care team after the visit due to the condition of the home.
Around the same time, leadership at the school attended by the oldest half sibling made a referral to children’s services regarding the behaviour of the mother towards her son in a meeting at the school.
These facts were passed on to the county council’s multi-agency team.
Members of the team, and a social worker, then visited the house and noted “poor home conditions”.
In the final months of the pregnancy, and first few months of the baby’s birth, there were “continued concerns” about the mother’s “parenting capacity and her ability to cope”.
During this time, the baby was hospitalised due to concerns around “failing to thrive”.
Failure to thrive involves a newborn’s insufficient weight gain or inappropriate weight loss.
One of the lessons which the safeguarding board is eager for local authorities to learn includes appropriate use of the county’s “early help service”.
Another lesson is: “The importance of always considering if a child is being neglected where failure to thrive is identified.
“If neglect is suspected, a child protection referral to children’s services must be made and a discharge planning meeting must be convened before the child is discharged from the hospital.”
The report continues that local authorities should always consider “the wider impact which a pre-birth/new born child can have on the parenting of siblings”.
It also says that local authorities must understand the messages around baby safer sleep awareness and convey them clearly to parents.
It says: “Where circumstances make you suspect unsafe sleep arrangements may be happening, these should always be explored and addressed.”
Derbyshire County Council declined to comment on the incident or the recommended lessons or disclose further details.
Advice from Derbyshire Community Health Services NHS Foundation Trust is as follows:
For the first six months a baby should sleep in a cot, crib or moses basket in the same room as the parent
If this is not possible, use a baby monitor to allow checks to be made on the baby
A baby’s feet should be placed at the foot of the crib, so that it cannot wriggle under the covers
Babies should be place on their back