Stoke & Staffordshire

Stoke baby death review finds 'poor communication'

Failures in communication between different child protection agencies in Stoke-on-Trent have been identified following the death of a baby.

A Serious Case Review has been carried out into the death of the baby who died in the care of a family known to social services and police.

The baby, who cannot be named for legal reasons, died in the winter of 2010, following a "life-threatening event".

They had been the subject of a child protection plan during their lifetime.

Stoke-on-Trent Safeguarding Children Board published a report of its findings on Wednesday.

Not breathing

The report makes a number of recommendations to various agencies.

It states that the child, while aged about three months, was discovered by their substitute carer, a family member, lying face down on a sofa, while "co-sleeping" with their father.

The child was not breathing and was taken to hospital.

The baby survived but continued to receive a high degree of medical attention and died a few months later.

The report found a number of failures including professionals involved in the case not always following accepted policies and procedures and records not having "sufficient detail".

It also said assessment of the risk posed by the baby's domestic circumstances "was insufficient".

Authorities who were investigated in the review included the city council's children's services, Staffordshire Police and Stoke-on-Trent and Staffordshire primary care trusts.

'No conclusive evidence'

It added: "The quality of inter-agency communication was generally evidenced as poor.

"There were numerous incidents of poor inter-agency communication."

But the review said there was no "conclusive evidence" to support the idea that, if alternative actions had been taken, this would have resulted in a different outcome for the child.

It said: "The overwhelming evidence is that relevant policies, procedures and guidance were in place, but that operation of them was inconsistent and in some instances inadequate."

Recommendations included Staffordshire Police reviewing how information held about children who are the subject of child protection plans is made available to frontline staff so that "timely risk assessment and interventions" can be made.

It suggested consideration be given to re-launching a campaign to reduce the risk of "cot death" and to raise awareness of the dangers of co-sleeping between babies and adults.

It was also recommended partner agencies scope the possibility of creating a single multi-agency service to assess the needs of children and families.


Sharon Menghini, director of children and young people's services at the city council, said it was important to "reflect on our practice".

She said: "[That's] both in my set of services, but also with our partner agencies and that's the role of the safeguarding board and we're committed to doing that.

"We've been very challenging of each other. We've been very heart-searching and open and transparent with each other."

She added: "This is about changing practice. It's about working with families, with schools, with other partners to make sure that for every child in Stoke we put in place the very best alert mechanisms, recognition mechanisms of risks and also support mechanisms for families that particularly need help."

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