Risks to Northamptonshire baby smothered by mother missed - report
Agencies failed to spot the risks to a baby who was smothered by their mother in bed after she had drunk heavily and taken cocaine, a report said.
Northamptonshire Safeguarding Children Partnership looked into the case of the baby who died in June 2020.
The report said the baby was only weeks old when the incident happened while they were co-sleeping in a double bed.
The local police force, ambulance service and integrated care board said they had since made improvements.
The mother was staying at a friend's house and the pair had drunk five litres of alcohol between them in the hours before it happened, the Local Democracy Reporting Service said.
According to the report, agencies worried "too much" about the mother's needs rather than how she could affect the baby and there was an "over optimism" about the mother's drinking.
The mother had a "significant history" of alcohol misuse but her own reporting that she was not drinking "appeared to be accepted" at face value, the report said.
Northamptonshire Police also missed two chances to issue police protection notices (PPNs) - referral forms highlighting concerns for a vulnerable child, it added.
'Raise awareness of risks'
The report said Covid-19 meant meetings were affected and the mother was able to avoid some that were face-to-face.
The East Midlands Ambulance Service (EMAS) had contact with the mother a few weeks before the baby's death, but she was "aggressive and hostile" while drunk, it said.
The ambulance crew completed a safeguarding referral but only included the mother's first name, which led to a delay.
By the time all of the relevant information was received, the baby had died.
EMAS carried out a Serious Incident investigation and made a series of recommendations, including to give a "clear guidance on immediate and urgent referrals", the report said.
Yvonne Higgins, chief nursing officer at Northamptonshire Integrated Care Board, said it had "looked at improving processes when potential child protection concerns are identified following attendance at an address".
She said the board and other agencies had been working "to develop and run a safer sleeping campaign, to raise awareness of these risks and encourage safer sleeping practices for babies".
A Northamptonshire Police spokesperson said it welcomed the report, adding: "Significant force-wide training has been completed since then and PPN numbers submitted by police have increased hugely as a result."
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