Independent review finds ‘lessons learned’ following death of eight-week-old Crowborough baby

The East Sussex Safeguarding Children Partnership (ESSCP) carried out the serious case review following the death of the eight-week-old baby in September 2018.

The child’s father has subsequently been convicted of her murder, and her mother of allowing her death.

While the names of the parents are not included in the serious case review, in March of this year Michael Roe, 33, was jailed for life with a minimum of 19 years for shaking his baby daughter Holly to death.

Holly’s mother Tiffany Tate, 22, who was found by the court to have turned a blind eye to his abuse and allowed him to kill their baby, was jailed for two years and nine months.

The review report, which examined the contact and support the family had with various agencies, has been published now that the criminal process has been concluded.

It highlights that the family received a wide range of support from health services and local authority social care teams, but this, ultimately, had not prevented the death of the child.

The independent chair of the ESSCP, Reg Hooke, said: “This tragic and untimely death of a very young and vulnerable child inevitably required a serious case review to understand whether anything more could have been done to protect such vulnerable babies.

“In this case we had a particular focus on the health and social care services.

“The aim has been to reduce the risk of something like this happening again.”

Mr Hooke said one key aspect was that both parents had, as children, been in care.

The review had highlighted the importance of local authorities continuing to offer support as a ‘corporate grandparent’ when children leave care and have children themselves.

He added: “A good level of support was provided to the mother during pregnancy and post birth by the local authority and this case underlines for me the need for care leavers who become parents themselves to receive ongoing support in the same way many new parents benefit from the support of their own families.”

The improvements identified in the review included better cross-border links between social care teams and the need for persistence and tenacity in professionals to ensure a child and carers are seen in person where they are believed to be vulnerable.

It also recommends that hospitals should make sure a discharge planning meeting is always held after a child’s birth to ensure that the right support is in place straight-away.

Among the other recommendations of the report, the ESCPP says post-mortems should be conducted as soon as practicable where a child dies in such circumstances, and that CAT scans should be considered immediately when there’s an unexpected infant death.

The Government’s Department of Health & Social Care has been asked to review capacity across the country in order to achieve this.

The report also found there had been no additional teenage pregnancy support for the child’s mother in the area she lived, and the fact that the mother had four midwives in a very short space of time because of capacity issues had created a challenging situation.

Mr Hooke said: “These very sad events took place some time ago and, although we’ve not been able to publish the report before now, we have been working closely with all the agencies involved.

“I am very pleased to say that the lessons this report identifies have either been or are being addressed.”