Support plan was 'prematurely' closed four days before baby's death in Kettering

A support plan was ‘prematurely’ closed four days before a baby died in Kettering, a review has found.

Fred Robinson was just 16-weeks-old when was he was found unresponsive on June 6, 2020, in what health professionals suspected was a case of ‘overlaying’.

His mum Lauren Robinson, who was known to children’s services, had co-slept with him and was under the influence of alcohol having also taken cocaine. She was later spared from prison after admitting neglect.

This week the Northamptonshire Safeguarding Children Partnership (NSCP) said there was ‘more than sufficient grounds’ to maintain a plan aimed at protecting Fred – named as child Ba in their report – rather than closing it just before he died.

Even before Fred was born in February 2020 safeguarding concerns had been raised, primarily because of concerns around domestic violence relating to his father, who was in prison for the entirety of his life.

Four months before the birth a child protection plan (CPP) was made under the category of neglect. This was later stepped down to a child in need (CIN) plan because of the mum’s progress, but a report by independent author Dr Russell Wate found professionals had relied on what she had self-reported.

His review said: “There was an impact of over optimism by professionals, particularly with the step-down process and closure, but there are several comments raised in the information recorded by professionals throughout child Ba’s case that do not provide assurance that risks to child Ba had been mitigated.

“What there isn’t provided for in meetings was if there was actually any evidence to support that there had been any positive changes? This only relied on what the mother self-reported as positive.”

The report said that although the domestic abuse that the safeguarding plan centred around was an “important factor”, the plan overlooked a number of other issues including: alcohol abuse, neglect of an unborn child, historic involvement with children’s services, housing issues, smoking, mental health and missing healthcare appointments.

The CIN plan was then closed on June 2 – four days before Fred died – but Dr Wate said he believed it was closed prematurely and that the actions of it had not been completed.

He said: “Hindsight bias in reviews can feature in reports, but in this case, there does appear to have been more than sufficient grounds for maintaining the CIN plan rather than deciding to close it.”

And he added that it was ‘unclear’ why the plan had been stepped down from a CPP to a CIN plan in the first place.

An East Midlands Ambulance Service (EMAS) crew had previously had been called to another incident in May where Fred was present. His mum had been drinking and medics saw a moses basket with a pillow placed over it. They completed a safeguarding review which was sent to the service’s safeguarding team, but it did not include Fred’s details and just gave the first name of his mum.

The report found: “Due to this the safeguarding team were unable to progress the referral and returned it to the attending crew asking for further detail. By the time the crew were able to get the information and return it to EMAS’ safeguarding team, child Ba had died.”

EMAS said in their report that police or social services should have been contacted immediately.

The NSCP report also said that there had been occasions where police should have completed a police protection notice – a referral form highlighting concerns for a vulnerable youth – for the unborn child but did not.

It also said that there is no doubt that Covid-19 had an impact as it allowed the mum to avoid any face-to-face contact and also meant the step down process was carried out less rigorously due to Covid-19 restrictions.

Two days after the CIN plan was closed Robinson took Fred to temporarily live with a friend after her mum challenged her over her alcohol consumption.

On the night Fred died his mum had shared about five litres of cider with a friend. A pathologist was unable to ascertain the baby’s cause of death. He also found that he had metabolites of cocaine in his system, which may have been through a contaminated bottle.

Four recommendations were made to NSCP, which included ensuring all professionals have a better understanding of the impact of parental alcohol misuse on children, the re-launch of the county’s safer sleeping campaign, checking that step down procedures are working “robustly and rigorously” and considering what needs to be put in place to support grandparents, and other family members, who they expect to act as a protective factor to parental risks to safeguarding children.

The NSCP report added: “Unsafe sleeping has been a factor in a number of recent child deaths in Northamptonshire. This has triggered a separate review of a refresh to current practice in relation to advice and support given to expectant and new parents around safe sleeping and how this can be further strengthened.

“A further repeated theme running through this review into the death of child Ba is that practitioners focused too much on the needs of the mother and overlooked the implications for her child and their lived experience.”

Cllr Scott Edwards, North Northamptonshire Council’s executive member for children, families, education and skills, said: “This is a tremendously sad case - child Ba was only a few weeks old when they died at the beginning of June 2020.

“The report has highlighted learning that can be adopted to make processes more robust and make children safer now and in the future and we unreservedly accept the findings of this report.

“While the period of time was before local government reorganisation took place in the county and the formation of North Northamptonshire Council, we recognise it is now our duty to work with partners to continue to act on recommendations outlined.

“Already we have led on a public health campaign to outline the very real dangers of co-sleeping and highlight some of the risks. It is our mission to work with all of our partners to make sure that every child is as safe as they can be and we will work tirelessly to this end.”

At the time of the incident Northamptonshire’s children’s services were rated as inadequate, but they have since been graded as requires improvement.

Children’s services are now run by Northamptonshire Children’s Trust, which is expected to overspend on its budget.

Julian Wooster, chair of Northamptonshire Children’s Trust, said: “This is an incredibly upsetting case, and we owe it to this baby, to ensure that the learnings from this report are put into practice. We accept the findings of the report and have supported the public health safer sleeping campaign to highlight the risks and dangers of co-sleeping. The Children’s Trust have also adopted the ‘signs of safety model of practice’, which ensures that all risks and dangers from any family member are considered.

“Whilst this very sad incident happened before the time of local government reform and the establishment of the trust, as an organisation it is our priority to take all steps to ensure that we support and safeguard children, working alongside our partners.”

Yvonne Higgins, chief nursing officer at Northamptonshire Integrated Care Board, which is responsible for local NHS services, said: “Our condolences remain with child Ba’s family at this very difficult time.

“We welcome the publication of the learning review by the child safeguarding partnership (of which we are a member). This was an extremely sad case where a baby has lost their life through co-sleeping.

“The learning review recognised the impact Covid-19 had on healthcare provision when at the height of the pandemic many families had concerns about meeting in person. In this case the family raised concerns about meeting face-to-face and the review recognised the persistent approach the health visitors took to ensure they maintained contact and support for child Ba’s mother and the wider family.

“It also acknowledged the good practice of the EMAS paramedics who provided safe sleeping advice to the mother when witnessing child Ba in an unsafe sleeping environment. As part of the review the organisation has looked at improving processes when potential child protection concerns are identified following attendance at an address, including when concerns are identified for a child who is not normally resident at that address.

“This case should act as a reminder to parents and wider families about the risks of co-sleeping, especially when alcohol and substances are involved. We have been working collectively with partners to develop and run a safer sleeping campaign to raise awareness of these risks and encourage safer sleeping practices for babies.”

Last year Robinson cried in the dock as she was sentenced to two years in prison, suspended for 18 months, with rehabilitation activities.

A family statement, written by Fred's grandfather, was read out in open court and described the baby boy as ‘perfect’.

It said he rarely cried and just squeaked a little – giving him the nickname ‘squeak’ – and said his death had taken a huge emotional toll on the family.

The statement read: "There is a saying that time heals all wounds. We have not found it to be so."