Eviction of vulnerable family led to baby's death, says serious case review

Social services’ and housing authorities’ failure to communicate put the baby at risk, says review

File photo (Rex Features)

A ten-week-old baby boy died on the night his family were evicted from their Warwickshire home, after being failed by the agencies who should have been supporting them, according to a serious case review. The circumstances around the death of the child, named ‘John’, emerged on 14 October. The baby boy was born six weeks prematurely. He and his sister Amber, who was under two, had been regarded as ‘children in in need’ by social services because of concerns over neglect.

His family’s eviction from their housing association property took place on on September 1st 2013 and they ended up staying with relatives. “They had to leave numerous things behind in the flat including a travel cot, nappies, children’s clothes and toys as there would not be enough room for them at the grandmother’s home,” noted the review. John had been taken downstairs for a feed and died after sleeping on the sofa with his mother. The dangers of the sleeping arrangements, with “a premature baby and high likelihood of mum falling asleep with him on the sofa” risk factors for Sudden Infant Death Syndrome, “were not ascertained,” by any of the professionals involved, it said. An open verdict into the baby’s death was recorded by the coroner in September 2013.

The review, published on 13 October by Warwickshire Safeguarding Children Board (WSCB), revealed that the family’s need for help was apparent months earlier. They had been threatened with eviction in September 2012, and in April 2013 John’s mother went to her GP to ask for an abortion. But since she was already more than 24 weeks pregnant “there was no choice but to carry on the pregnancy.” The family’s “social situation or social needs were not considered” and “there was no consideration of the impact upon Susan of the unplanned pregnancy, or if there could possibly be any safeguarding issues to consider.”

Agencies involved with the family “were not effectively communicating with each other,” something which the review claimed is a national problem. Days after John was born a health visitor referred the case to social services, after “concerns were expressed around the state of the home,” and “Susan’s ability to care for a premature baby and a toddler who also had additional needs with developmental delay.” But the mother’s “mental health was not further probed or discussed with the GP as it should have been.”

A lack of communication resulted in the needs of the family not being recognised and “the focus became centred on eviction and not support and the vulnerability of the children and the family was not appreciated,” according to the review. “There was no liaison between the housing provider, the Local Housing Authority and any of the other agencies involved with the family about the impending eviction and the impact this might have on the family.”

And it warned that a lack of understanding by professionals across all agencies of the impact of eviction and the eviction process on a family “increases the chance that children in these circumstances will be left vulnerable.” In Warwickshire there is a “pattern of disparate information sharing across agencies increasing the risk that important information relevant to keeping children safe will be overlooked.” The review added: “This finding has the potential to affect all families because in a family with a new-born baby there will always be more than one agency involved, at the very least a GP and health visitor...This is a national issue, as well as a local one.”

Joanna Nicolas, independent author of the report, commented: “The agencies working with this family had not fully understood the issues at the heart of the case, and could have done more to mitigate the impact of the family’s eviction.” And David Peplow, chair of WSCB, said: “This is a deeply saddening case and on behalf of the board we express our heartfelt sympathies to the family for the loss of their child. A number of agencies were in contact with the family and, although child protection issues were not a causative factor in John’s death, we feel that there is important learning for all.” He added: “We want agencies both in Warwickshire and nationally to learn from this case and improve practice.”