A review into the death of a baby on Teesside has heard how there were “missed opportunities” to spot neglect.
The three-month-old, named Emma, was found unconscious in her pram in May 2020 after being propped up with inappropriate bedding.
She died from suspected asphyxiation, the safeguarding board said, after her head fell forwards, restricting her airways.
It said agencies did not identify she was at increased risk.
Police and paramedics responding to Emma’s death described her home as being in a “chaotic state” with “faeces and nappies strewn around” and blankets in the pram “covered in mould”.
A nurse who examined her after death said Emma’s nappy rash was “the worst she had ever seen” and that it would not have occurred overnight.
In its report, Hartlepool and Stockton on Tees Safeguarding Children Partnership said: “There were a number of incidents over the preceding few months that cumulatively increased need and risk, and could have been predicted.”
It said against the backdrop of the first pandemic lockdown, professionals had “reduced multi-agency oversight and closed the case”.
“The timing of this decision meant that partners were unable to recognise this rapid decline,” it added.
The report said in the weeks leading up to Emma’s death, her mother had to care for four children with little support, while Emma – who was born premature – and another sibling had been hospitalised with chest infections.
The family also moved homes in the months before her death.
“Taken together with the fact that Covid ‘lockdown’ had begun and the family were being stepped down to early help, these stresses were not noticed by professionals,” it added, who had relied too much on the mother’s “ability to parent”.
It said the family had seen a “sudden” and “dramatic decline in living conditions”, which had not been identified by professionals.
While those “were not the direct cause of her death” the report said they were indicative of a mother who was struggling to cope and who was not therefore meeting Emma’s needs and ensuring that she was in a safe sleeping position.”
The report noted that despite there being a cot in the flat it had not been used and Emma had been sleeping in a pram.
Among the recommendations, Hartlepool and Stockton on Tees Safeguarding Children Partnership called for a better explanation and support when it came to helping families ensure babies slept safely.
Other points raised included more “professional curiosity” by workers, and understanding the underlying trauma that parents – the mother in this case – had faced.
Since Emma’s death, the board said steps had been taken to “address single and inter-agency working” as well as improve communication.
Staff who were involved also participated in an online learning event in November 2020, it said.