Baby co-sleeping death prompts social services review

An investigation was launched after the Lancashire tot, who had been under a care order since shortly after her birth but remained with her mother, died in February 2021.

Now a children's safeguarding practice review into the death of the baby, referred to as Lily, not her real name, has finally been published, three years on.

The report says: "Lily was found unresponsive and could not be revived.

"It is believed that the mother co-slept with Lily after drinking alcohol. Police investigations found a bottle of vodka in the mother’s room."

The inquiry heard Lily and her mother had spent time previously in an assessment unit, where concerns had been expressed about the pair co-sleeping and the mum's 'rough handling' of the child.

Social workers had also been worried about the mother's self-care and mental health during the assessment period.

Independent reviewer Louise Rae noted an assessment review believed "‘it would not be responsible...to recommend mum and Lily live independently in the community together as mum still requires support in many areas."

She also reported, when Lily and her mother took up a later temporary placement, that their foster carers were initially unaware they should be checking for co-sleeping issues.

The fostering agency and local authority had failed to pick up on the fact this had not been checked in the daily logs completed by the carers.

Five days into the placement the foster carers raised concerns with social workers about the mother's self-care and general appearance.

On the sixth day, she was seen co-sleeping with Lily, which was also reported to social services.

The reviewer said "there was a lack of professional curiosity around the issues impacting on mother's behaviour or addressing the underlying concerns."

Five days before Lily's death, the social worker responsible for the case left the local authority.

The case was not allocated to another professional subsequently - there was no forward plan in place for Lily and her mother and funding was in fact running out for their foster placement.

The reviewer made seven recommendations for professionals in light of Lily's death, focusing on placement and care planning, risk assessments and decision-making.

One specific point related to co-sleeping concerns is being clearly addressed in placement plans so foster carers can check babies remain in cots.

Another stressed social services should ensure a 'full handover' takes place of allocated cases when a social worker leaves their employment.

The reviewer did note the drinking on the night of Lily's death was believed to be a 'single event' and there was "no evidence to suggest that the mother was drinking alcohol and this had not been a feature of previous concerns".

Louise Anderson, Lancashire County Council children's social care director, said: "The death of any child is such a tragic loss.

"I would like to personally extend our sincerest condolences to everyone affected by this loss.

"It is essential to emphasise that the safety and well-being of every child under our care are our utmost priorities.

"We recognise tragedies like this underscore the critical importance of continuous improvement and vigilance within our multi-agency systems.

"We are fully committed to implementing any necessary changes that have emerged from this review. We will take on the report's recommendations around the importance of early placement planning and further trauma-informed work."

Prof Sarah O'Brien, chair of the Lancashire Children Safeguarding and Assurance Partnership Executive, added: "This series of events was incredibly sad and we will do everything we can to ensure we prevent this in future.

"We will fully take on board the recommendations of this report, including improved planning and clarity around the risks of co-sleeping and the need for detailed, up-to-date multi-agency assessments."