The NHS South West report found that health professionals could have prevented the death of a 10 day old baby who was smothered by his severely depressed mother.
Katy Norris, who smothered her new baby Leo, referred to as Baby Y, with a pillow in April 2010, was severely depressed to the point where professionals did not know the best thing to do.
Before the death of her son, she was seen by four mental health experts, two GPs, at least seven midwives or maternity care assistants, a consultant obstetrician, a health visitor and a nurse practitioner.
This was due to the severity of her long term depression, and so she was passed from one professional to the next, leaving no one to take the responsibilty for her's and Leo's care.
The investigation concluded that the death of her baby was preventable, as each professional recognised the problem and yet none considered themself responsible for safeguarding Leo.
Katy Norris had a history of mental illness and in 1998 had tried to kill herself by taking drugs and alcohol at 19 years of age. She was prescribed antidepressants. During her pregnancy she initially stopped taking her drugs but began again when she found she could not cope without them.
The report found a lack of action by professionals to take “assertive and timely” action to address Norris’s depression had caused her “mental state to deteriorate to the point of killing” her child. Professionals had also failed to identify the potential risk to Baby Y from his mother’s deteriorating mental health.
As a result, they failed to trigger the safeguarding children procedure “in a timely manner” and “no inter-agency management plan was put in place to manage the risk” to the child.
The report concluded that co-ordinated care had failed:
It is never a straight-forward task to make a direct causal link between an act or omission on the part of mental health care professionals and a homicide perpetrated by an independent third party.
However the Care Programme Approach is an evidence-based process which is widely accepted as being an effective method of ensuring the continued health, safety and wellbeing of service users and those around them.
In the case of Ms. X the most basic building blocks of the Care Programme Approach were not implemented and the independent investigation team concluded that this was to the ultimate detriment of the health, safety and wellbeing of both Ms. X and her baby.
Alison Moores, the director of nursing and practice at Devon Partnership NHS Trust, said they have taken the report very seriously and already made significant changes:
This is one of the most tragic cases we have seen in the south west and I would like to offer my apologies and heartfelt sympathy to the family.
It has had a significant impact upon the staff concerned, and our organisation as a whole, and we take the report’s findings very seriously indeed.
What is clear from both reports is that, in the week's leading up to the incident, there were a number of missed opportunities to identify the risks, to respond to them appropriately and to ensure that a joined-up approach was taken to providing the necessary support and safeguarding action.
The result was the tragic death of a baby which, the independent investigation report finds, was preventable. Since this death occurred, a number of very important changes have been made.
Foremost amongst these is the system-wide development of robust child safeguarding arrangements right across the county.
Three years ago, these were in the early stages of development but we now have clear, rigorous systems in place which involve representation from health, social care, local authorities and the police.