Report finds nothing could have been done to prevent tragic infanticide case

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An independent review commissioned by the Lincolnshire Safeguarding Children Board into the death of a newborn baby has concluded that there was nothing that agencies could have done to prevent the tragedy.

The serious case review was commissioned in April 2014, following the incident which happened in September 2013. The baby boy was born and died on the same day in a village near Bourne and his 16-year-old mother subsequently pleaded guilty to infanticide.

In September 2014, she was sentenced to a 24-month youth rehabilitation order combined with a supervision order, after she admitted at an earlier hearing that she choked her son.

The Lincolnshire Safeguarding Children Board commissioned the review to look at any agency involvement in the year prior to the birth to see if anything could have been done to prevent the tragedy after the mother concealed or denied the pregnancy. The review panel included contributions from senior managers or designated professionals from key statutory agencies.

In conclusion, the report author states: “The presenting information and the challenges of identifying concealed/denied pregnancies made the task of preventing this tragedy an impossible one for all agencies involved. This is also a view voiced by the young mother as she did not feel that there was anything that could have been done differently by services.”

Chairman of the board Chris Cook said: “This is a tragic case involving a young girl and our thoughts are very much with her and her family who have contributed to this review. Our thoughts are also with the father and his family. Clearly the conclusion states that the baby’s death couldn’t have been foreseen. The overview report states agencies had little opportunity to intervene or assist as the pregnancy was concealed and the mother did not present with the typical signs and symptoms of pregnancy - in particular there were no visible physical cues of pregnancy.

“Where there was limited professional contact with the mother the professional advice or action would not have altered this sad and tragic outcome according to the author of the review.

“There is always the opportunity to improve practice however, and recommendations have been implemented for GP health care services to increase knowledge of concealed pregnancy and birth, improved access to psychological therapies and better training for GP practices and Registrars. It’s also good practice for schools to ensure they have adequate training and Education Welfare Officers are used effectively.

“However, overall the main and significant learning from this case is that there is little research evidence and guidance for professionals working in this complex and challenging area where mothers conceal their pregnancy.

“Whilst the LSCB will develop its own multi-agency guidance on this area what is really required is for there to be some national research on this topic which could lead to national guidance being produced for the benefit of all professionals. Accordingly, the LSCB will be writing to the Department of Health to recommend that they develop a repository of research on concealed and denied pregnancies. We will also be developing our own multi-agency good practice guidance.”

The full report and recommendations which have been implemented are available by visiting the board’s website.