According to a review by the Liverpool Safeguarding Children Board in the U.K., a 6-month-old baby who died shortly after being released to her parents had cocaine, painkillers and antidepressants in her stomach at the time of her death.
The baby, identified by the pseudonym Mary, died in 2013. The drugs were not linked to her death, but the review called highlighted the systematic negligence that allowed the baby to be released into the custody of her drug-abusing parents.
“Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy,” said chairman Howard Cooper. “It cannot be inferred that child Mary’s death was preventable, but there are lessons to be learned for all the agencies involved with this family about multi-agency working.”
Mary had three other siblings and her parents had been under investigation by social services several times since 2008. Mary died in July 2013 after she was born prematurely with several medical issues, including a heart murmur.
A community nurse tried to visit Mary’s home after she was released from the hospital, but she had trouble accessing the house. Another health care worker went to the house the day before Mary died, but was not allowed inside the house.
Police found drugs, a syringe and beer cans at the home and Mary’s mother admitted to using cocaine and marijuana.
The cause of Mary’s death was ruled “unascertained” due to a lack of evidence.
“Whilst agencies had some concerns about the older children, they generally worked to single rather than multi-agency agendas and processes,” the report said. "There was some evidence of good informal liaisons such as between the school and the education welfare officer, or the school and school nurse, but generally the level of inter-agency communication required to support a family with four children was not achieved.
"Child Mary was a vulnerable child and a discussion between health professionals may well have highlighted important information about (the mother’s) history of not engaging with health services in respect of her children and the shared information may have led to further action.”
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