Coventry Baby C's bath death was 'not preventable'
The death of an 11-month-old boy who was left unsupervised in the bath could not have been predicted or prevented by professionals, a report has found.
A serious case review was launched when "Baby C" died after being left in the bath with his two-year-old sibling in Coventry in April 2014.
The family was known to social services for two years over concerns including domestic violence.
The report found care "shortcomings" were not linked to the baby's death.
Social services first became involved with the family in June 2012, before Baby C was born, the document said.
His mother told a GP she was feeling "low" during a six-week check-up on another child but a health visitor was not informed.
Six months later, she was 18 weeks pregnant with Baby C and attended the community midwifery clinic six weeks later than normal, saying she had "tried to ignore the problem".
'Abused by father'
When Baby C was born, a health visitor had regular contact and judged his progress to be "satisfactory".
Before Baby C was six months old, police were called three times over disputes between his mother and maternal grandmother but these were not passed on to other agencies.
His mother later told the health visitor "she had been physically, emotionally and financially abused by the father for the last 18 months and the incidents were becoming worse", said the report.
The following day, the health visitor made a referral to children's services.
She had made an appointment for the mother with the domestic violence service - but she did not attend.
In April 2014, Baby C was taken to A&E by ambulance after being found submerged in the bath.
Baby C was on life support for four days before it was switched off.
The report found the referrals made were correct, but the information that would have helped at each stage was lost or not acted upon.
The failure to investigate the mother's well-being meant the impact it was having on the family was not understood, said the report.