Baby’s death sparks series of recommendations

The tragic death of a 15-month-old baby who suffocated while caught in a high chair has sparked a series of safeguarding recommendations in Essex.

The six recommendations made to the Essex Child Safeguarding Board comes after the child, named as Child I, suffocated to death after being caught in a high chair while in the sole care of their father.

The father had denied being an habitual cannabis smoker at the time but had previously suffered a drug induced psychosis and psychiatric hospital admission.

Among the recommendations include that the Essex Safeguarding Children Board (ESCB) develop a multi-agency substance misuse strategy to provide clarity on the impact of different substance misuse, particularly cannabis on parenting capacity.

The review said cannabis use has become increasingly normalised over the last few years and is prevalent in many families. The review said it was unclear how much of a risk it posed. Additionally it is not clear where the risk meets the threshold for a referral to children’s social care.

Child I was found by the father caught in a high chair, became asphyxiated and subsequently died. The inquest for Child I in May 2021 made a ruling of accidental death and criminal proceedings were not pursued.

Child I was the third child of four children whose mother died of natural causes two months prior to the child’s death. The father had abused substances historically and at one point this resulted in a drug induced psychosis and psychiatric hospital admission.

Throughout contact with child services from 2017, there were consistent concerns raised around the smell of cannabis inside and around the family home. The father would consistently deny that he smoked cannabis, and although the social worker saw no evidence at the home, it would appear he had subsequently stated he had continued to use cannabis.

In the six weeks between the mother’s death – just 11 days after the birth of the youngest and fourth child and the death of Child I when they were 14-months-old – a social work assessment had been initiated to assess the risk and support needs of the father.

This concluded here was an overall level of chronic neglect of the children affecting different areas of development including education, health and basic care needs.

The assessment that had been initiated during this time made it clear that despite support, although the father understood what was required the evidence was that he was not able to manage taking children to health appointments or make school applications for Sibling 1 and Sibling 2.

It was felt that his practical abilities to cook, feed and wash the children and maintain acceptable standards of cleanliness in the home was very limited. The children were not being toilet trained and Sibling 1 was still in nappies at five and a half.

The conclusion of the assessment was that there was an overall level of chronic neglect of the children affecting different areas of development including education, health and basic care needs.

A statement as part of the review said: “Due to the nature of the concerns and the ongoing patterns of behaviour over the years, it was felt that no significant change has been made even with the mother in the home, given the recent concerns of the midwife over home conditions and the smell of cannabis.

It added that the father appeared to be coping but much of this was due to support from others in the community.

The assessment states: “Due to a lack of change, lack of consistent engagement with professionals and continuing concerns raised around neglect, recommendation is for the case to be taken to child protection consultation with a view to initiate ICPC (Initial Child Protection Conference)”

However, the the social worker undertook a child protection consultation and confirmed the intention to move to Child Protection Conference on the day of Child I’s death.

The review concludes with six recommendations – firstly that ESCB update the Essex County Council Child In Need guidance and second that ESCB consider improving local child protection procedures to provide opportunities to consider risk and support for families.

The third recommendation is that ESCB to develop a multi-agency substance misuse strategy to provide clarity on the impact of different substance misuse, particularly cannabis on parenting capacity.

The fourth recommends ESCB to consider how to support professionals to manage the arrangements for children with special and additional needs within early help arrangements.

Recommendation 5 asks to consider any resulting actions from the national panel’s thematic review “the myth of invisible men” published in 2021. This identified a number of recommendations to support the engagement of men and a ‘Think Family” approach.

Recommendation 6 asks ESCB to consider the national panel’s review “Child Protection in England” 2022 to ensure that the views of family members are always considered in assessments of risk.

An Essex County Council spokesperson said: “This recommendation relates to the time when the oldest child of the family was on a child in need plan in 2017/18.

“The importance of contingency plans when children in need are stepped down to early help is fully recognised and is included in the revised child in need practice guidance circulated in March 2023.”

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Piers Meyler

Local Democracy Reporter