The tragic case of a Norfolk baby, who died after their intoxicated mother took them into her bed must lead to changes in how social workers deal with neglect, a review has found.
The baby's mother had been drinking and smoking cannabis during the day and had taken the infant into her bed later that night, where the four-week-old died.
A coroner recorded an open conclusion on the death of the baby at an inquest, but, because the family was known to Norfolk County Council's children's services, it triggered a Child Safeguarding Practice Review.
And that review, in which the child is referred to as Child AK, has made a string of recommendations to change how long-term neglect is recognised and tackled by social workers and other agencies.
The report said there had been "drift" and "indecision" over what needed to happen with the family, which included four other children, all of whom had different fathers to Child AK.
Various services, including Norfolk County Council, had been involved with the family for at least 10 years, with "concerns about neglect in maternal care".
The report said there had been "long-standing concerns about the misuse of drugs and alcohol by mother, and some of the fathers, alongside concerns about maternal emotional wellbeing, ‘physical chastisement’ and domestic abuse."
While workers involved with the family said children had suffered "long-term" neglect, the report said the parenting was "seen as not quite good enough but not quite bad enough to lead to higher thresholds of intervention".
A number of recommendations have been made around how neglect is assessed and monitored, ways to better involve fathers when working with families and improved assessment of the impact of parental substance abuse on children.
But the report stated: "It is important to note that had all these services been in place at the time, there is no guarantee that Child AK would be alive today."
Chris Robson, independent chair of Norfolk Safeguarding Children Partnership, said: "It is clear from this review that despite extensive support from multiple professionals, there wasn’t full recognition of the impact and risks that neglect posed to AK and their siblings.
"We are already acting on the recommendations of this review by further developing how we work with dads and family networks and bringing multiple agencies together in supervision sessions."
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