Coventry baby death: Staff told to improve on neglect detection

A probe of authorities' handling of a case involving the care of a baby who later died has called for staff to better identify neglect



The serious case review followed the June 2019 death of the infant when he was two months old.

The report referred to him as Matt, who lived with his parents in Coventry.

Coventry Safeguarding Children Partnership (CSCP) said it would look at its practices to see where improvements could be made.

The report said the cause of Matt's death had not been formally determined and the review was conducted on the basis that abuse or neglect were suspected.

It said there was evidence at the time the parents had used cannabis and, or, alcohol on the night of Matt's death.

According to the report, while Matt's parents were initially arrested, the Crown Prosecution Service decided to take no further action after examining the case.

The review focused on the period from when an elder sibling was born in February 2018 to the date of Matt's death in June 2019.

It said following the sibling's birth, the family were referred to children's social services by a midwife who was concerned she had not been engaging with a home visiting service designed to help young parents.

The report noted several occasions where concerns were raised about the "poor" condition of the family home, the sibling's sleeping arrangements, and times when the parents would not allow agencies access to the property.

When a plan was put in place that police would be called if the parents avoided contact, it was not followed through, the review found.

It said while concerns of neglect had been identified, there was "little evidence" any investigation was made into the causes.

It added there were ongoing concerns about the parents using cannabis, but what "impact" this may have had on the children was not "effectively considered".

The case also lacked "overall coordination" across the multiple agencies involved, the review found.

"All agencies need to be sure that practitioners understand and are able to identify neglect and be aware of the lived experience of the child/children in the family home," it said.

A total of seven recommendations have been made to the CSCP which includes Coventry City Council, a local clinical commissioning group and West Midlands Police.

How many deaths does there have to be before someone in the council is finally held accountable?

If, and that is a big if, Dutchman, anyone is held accountable it will be the lowest rank of worker, rather than those that set policy, direction and staffing levels, which is where responsibility ought to lie.