Poor sharing of information led to warning signs being missed before a 19-day-old boy was murdered by his mother, a serious case review has found.
Nicola Brown, 43, was found guilty of the murder of her son Jake following a trial at Winchester Crown Court in 2016 and was sentenced to life imprisonment to serve a minimum of 14-and-a-half years.
The serious case review, carried out by the Portsmouth Safeguarding Children's Board, found that information sharing between agencies, including hospital staff and GPs, was inadequate.
Its conclusion states: "In this case the exchange of information between agencies was left wanting, particularly in relation to the adults' respective histories.
"Some incomplete exchanges of information between the police, children's social care and the health visitor about the historical and current issues relating to domestic abuse meant that more targeted services were not offered to the family at an early stage."
The report stated that Brown had a history of anger management, anxiety and depression and the child's father, Jason Brown, 44, who was acquitted of causing or allowing the death of a child, had a "troubled childhood" and issues with excessive drinking.
Dr Richard John, Portsmouth Safeguarding Children’s Board, Chair said: “The death of a young baby in such distressing circumstances has been difficult for everyone involved, especially for the wider family who are still coming to terms with their loss. As an independent safeguarding board we look at the events surrounding an unexpected child death to identify whether anything could be done to prevent a similar case happening again. Our review showed there were no major failings, all the agencies involved responded appropriately and promptly reacted to concerns. This was a complex case, involving a criminal trial where a mother was prosecuted for murder. We have made recommendations for improvements in sharing information between organisations, and are pleased to see that professionals across health, police and social care are now co-located in a multi-agency safeguarding team. As a safeguarding board we would urge any family who feels they are struggling to cope with young children, or concerned about a partner’s behaviour, to seek help. Families are often fearful that involvement from professionals means children will be taken away, when often the best outcome for children is to keep families together. But it’s vital that families are open and honest so the right help can be offered and situations don’t escalate resulting in devastating consequences.”
Alison Jeffery, Portsmouth City Council, Director of Children’s Services said: “This has been an incredibly tragic case for everyone involved, the death of a young baby is distressing and our thoughts go out to the wider family who are still grieving. We have used the Serious Case Review to take a critical look at how we work. We welcome the report’s findings into establishing a robust protocol for concealed pregnancies and this protocol is now in place. There are many ways parents can get help if they’re finding it difficult to cope, they won’t be judged, but they will be supported.”
Theresa Murphy, Portsmouth Hospitals Trust, Chief Nurse said: “The death of any child is desperately sad and shocking for everyone involved. When a child dies in circumstances like these it is essential that all organisations involved review their actions to identify any opportunities for learning, to prevent recurrence. Whilst the independent Serious Case Review did not identify any failings in our service provision, or any obvious opportunities to predict and therefore intervene in this case, there were some best practice recommendations to improve care for all children and their families. Portsmouth Hospitals NHS Trust has worked promptly with other professionals and agencies to embed learning and further develop local practice.”
Sarah Austin, Solent NHS Trust, Chief Operating Officer and Commercial Director said: “As an organisation that was involved in the care of this family, we have had questions of our own and as such, we fully engaged with the legal process as well as the Serious Case Review so that together we could find answers. Although both processes have not found any failings with the service we provided to the family, there are indeed some lessons we have learned and will implement. We will continue to work, as an organisation, and in partnership with others, to remove as many risks as we can predict so children in our care do not come to harm.”
Innes Richens, Chief of Health & Care Portsmouth said: “We recognise that the death of any child is a tragedy for the family and the wider community, but a death in these circumstances is particularly distressing. In this case the findings of the independent Serious Case Review did not identify any failings in health services in Portsmouth. However it is still important that we, and all agencies involved, reflect carefully and thoroughly on what led to this tragic event to ensure that we can put improvements in place to minimise the risk of this set of circumstances occurring again. The Review did make some recommendations that reflect best practice approaches adopted elsewhere in the country and the Clinical Commissioning Group has worked with our providers and partner agencies to embed these recommendations into practice. This has included updating the procedures we all need to follow to establish a more robust process for managing concealed pregnancies.”
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