Baby died after 'huge failings' by care staff: A mother with a conviction for attempted infanticide and history of depression was allowed to take home a newborn child. Stephen Ward and Mike Walsh report

SOCIAL WORKERS and hospital doctors allowed a mother with a conviction for attempted infanticide to take home her newborn child, a court at the Old Bailey was told yesterday.

Within weeks Christine Gibelli, 36, of West Norwood, south London, who had a history of post-natal depression, killed the new baby, Mia, the court was told. Lambeth council admitted yesterday that the death had exposed huge failings in its social services department.

The council published the results of a series of inquiries into the circumstances of seven-week-old Mia's death last June, which blame delays and confusion among various agencies, including its own social workers. The report also says such deaths will sometimes inevitably occur.

After she left hospital, a doctor at the Maudsley Hospital who knew her case history, Dr Channi Kumar, wrote to Lambeth social services warning of the risk to Mia, and asking for assurances that Gibelli was receiving intense monitoring.

Gibelli had been visited at home by a 'battalion of carers', the court was told, but despite her history - she had thrown her previous baby out of a third-floor window - she was not kept for constant observation in hospital, as one doctor had advised.

Instead she was allowed home under the treatment of Dr Katherina Dalton, a Harley Street specialist, who has pioneered a controversial hormone treatment for post-natal depression. The community midwife had visited on eight occasions and other health workers on five. Social services made six calls and a probation officer saw Gibelli three times.

But one morning, after failing to receive her daily hormone dose, Gibelli drowned the baby in a few inches of water in the kitchen of her council flat as her boyfriend dozed in bed. That day she was to have attended a much delayed case conference to discuss the future of her baby.

She pleaded guilty to infanticide. Judge Lawrence Verney, the Recorder of London, ordered her to be detained until doctors considered she was cured.

Gibelli had two other daughters - both in care - when Mia was born on 6 May last year, Anne Rafferty, for the prosecution, said. She had suffered psychiatric problems 'which began with the birth of her first child when she endured post-natal depression'.

In mitigation, Alun Jones QC, said: 'It is clear she drowned the baby in the knowledge she was to attend the case conference later in the day. She realised she would have to go to the social services. She felt she might be criticised and simply felt she was not capable of making the physical and mental effort to get the baby and herself dressed and be there on time. She was acting under severe mental illness.' Numb with shock, she told police afterwards she had not been able to cope when she drowned the baby.

She said: 'It has been a nightmare. I was not doing anything right - I was not being a good mother.'

Dr Dalton said after the case that she had previously treated 300 to 500 mothers with progesterone, including some who had killed earlier babies, and there had been no previous case of infanticide during treatment.

Lambeth council's report concludes that such tragedies cannot all be prevented. 'Children will continue to die from injuries inflicted by their guardians in circumstances where social workers are involved . . . because as a society we value parents' rights so highly that we weigh them in the balance against children's lives.'

The report makes a number of basic recommendations in the light of the death. Many have already been put into effect. These include:

Cross-referencing patient files between different agencies. Gibelli's previous attempted infanticide was not known to many staff handling the case;

All agencies to attend pre-birth conferences of high-risk babies. Many staff involved after the birth were unaware of contingency plans to use the law to prevent her going home if necessary;

All staff to read case files. Many key staff had not done so in this case;

Staff must read official manuals on babies at risk. Again, many had not even seen several basic books of rules and guidelines;

Staff must call case conferences urgently. In the Gibelli case, diary clashes saw the date slip back eight weeks;

Crucial information must be shared immediately between social workers, doctors, health visitors and other agencies;

Review the effectiveness of training. One key social worker had just been on a course, yet the mistakes still happened;

The area office involved to be thoroughly overhauled. The report says morale was low because of 'the state of the building, the high bombardment rate and the problems with recruitment and retention of staff'.

Steve Whaley, the council's leader, said: 'The council accepts the errors made in this case. However, there is no denying that the workload placed on staff poses great difficulties in their struggle to act in the best interest of the many children in need.'

(Photograph omitted)