A severely disabled baby girl found dead at her home was not properly cared for by her parents, according to a significant case review which also found opportunities to intervene were missed.
Child D was found “lifeless” by her father in the Glasgow family home at 2am – before she reached the age of one. She was taken to hospital but staff were unable to resuscitate her.
In the weeks leading up to her death, medical staff had raised concerns that she was not “her normal smiley self” and was losing weight.
Her complex needs included having to have her bladder emptied four times every day – but the care review found this was only being done “intermittently” by her parents. It concluded, “the child ultimately dies due to a poor care regime by the parents.”
Both parents have since been charged in connection with their daughter’s death. They and Child D cannot be identified for legal reasons.
The Glasgow Child Protection Committee has published a Significant Case Review into the death, which happened in July 2017.
It said “early intervention opportunities” were missed to help Child D and there was “a lack of coordination of services resulting in insufficient communication and information sharing.”
Problems in the system leading up to her death included three different health visitors being involved with the family. And there was no single health lead professional being made responsible for coordinating her health care.
It also found a GP had failed to flag up relevant details about the family history while filling out information for other health professionals and raised concerns about a pre-birth care assessment.
And it highlighted seven priorities that needed to be looked at in the wake of the child’s death.
The family had been known to social workers for a number of years. The baby’s father had drug addiction problems while the mother suffered from “long standing” mental health problems.
But they were judged to have made significant progress before the birth of Child D.
The review found that even before the birth of Child D there were concerns that she may not survive childbirth, and it was highlighted that if she survived she would have multiple health needs.
Despite this, a pre-birth meeting did not have any representation from acute health specialities involved in Child D’s care.
Child D underwent surgery after being born with spina bifida, which is when the baby’s spine and spinal cord do not develop properly in the womb.
She spent seven weeks in the neonatal high dependency unit before being taken home. Her health condition meant she needed to attend medical appointments regularly.
The review said there was “limited discussion around the child’s complex medical needs and what is expected of the parents with regards to the child’s daily health and care needs.”
This included the need for her to be catheterised four times every day to empty her bladder to stay healthy.
From August to December 2016 the child was seen by 13 health professionals. Parents promised health workers they were catheterising the baby four times daily, but no members of staff saw them do it at home.
At one point her dad told an addictions worker he was not “comfortable” catheterising his daughter.
The case review reported that in the hours beforehand Child D’s father had texted her mum begging her to come home as the baby was being sick and he didn’t know what to do.
Police were concerned about the state of the family home when they attended after Child D’s death. A stockpile of catheters was found in the home – suggesting it was not happening enough.
The case review said: “There are indications that the parents are not catheterising Child D four times daily as is necessary to ensure her health and well-being. They would appear to have been intermittently undertaking this procedure and the child ultimately dies due to a poor care regime by the parents.”
The case review identified seven priority findings when looking at the circumstances of her death including lack of communication and information sharing between agencies.
The review called for changes across the city including setting up a “process for identifying early in pregnancy vulnerable women and unborn babies who may require additional support.”
It also said it is necessary to have a “consistent approach” in the completion of GP SCI gateway information across the city – in light of a GP not filling in a form comprehensively about Child D’s family. Additionally, the review pointed out there is a need to ensure that all relevant agencies are represented at child protection meetings.
Findings included three different health visitors working with the family during Child D’s short life. It resulted in a lack of knowledge of the family and child’s needs. There was a shortage of health visitors at that time nationally but more have now been hired.
Another outcome showed a GP clicked ‘not known’ when asked were they aware of any vulnerability or child protection in relation to this pregnancy? while filling in information for maternity services. That happened despite the family being registered with the practice since 2013.
A further discovery revealed specialist health services staff didn’t attend a post birth planning meeting for Child D. The review said that had led to “the needs of the child not being fully understood and multi-agency assessment and decision making compromised.“
The review also highlighted no single health lead professional was assigned to the child.
The case review said: “If there is no health lead professional, there is no holistic understanding of a child’s Personal Data needs and there is no coordination across health specialities to ensure robust information sharing and care planning.”
It pointed out there was no consideration around “respite to support the parents to provide long term care to ensure a sustained high level of care for Child D.”
It also found there was “no multi-agency child’s plan in place and therefore no regular reviews of the plan involving key professionals.”
It showed concerns around Child D’s weight, mum’s mental health and the parents’ separation were not addressed along with other issues.
The review also raised concerns about NHS Greater Glasgow and Clyde health board having multiple information systems.
Child D’s information was recorded in different records.
It said: “Where health professionals do not have access to all relevant information this impacts on the quality of assessment, decision making and robust child’s planning.”
A spokeswoman for Glasgow’s Health & Social Care Partnership said: “This is a tragic case and our sympathies are with everyone affected.
“We welcome the findings of the Child Protection Committee’s report and have implemented an action plan to address the points raised – particularly in relation to information sharing between health and social care services.”
Story by local democracy reporter Sarah Hilley