A 10-week-old baby girl died after being left in a car seat overnight in a hotel room, a serious case review has revealed.
The girl, referred to as ‘Child M’, was one of three of the couple’s young children to die over a two-year period.
The Wigan Safeguarding Children Board report said Child M had been born prematurely and was therefore in the high risk category for ‘sudden and unexpected infant death’.
Although health and social services professionals had spoken with the parents ahead of a four-day family holiday about safe sleeping arrangements, Child M was left in the car seat because carry cots were ‘too heavy’ to carry up three sets of stairs.
The report has made 11 recommendations following the ‘potentially predictable’ death, although it has also highlighted examples of good practice by social services.
Police, who carried out a criminal investigation and brought no charges, verified the parents had checked on the three infants left in the room after they were put to bed around 7pm.
Child M was found unresponsive by her father at around 10am. Following an inquest, the coroner reported a narrative verdict, which read: “Having been fed at 2.30am, Child M fell asleep whilst secured in a car seat which was placed in an upright position on a bunk bed in a room of a hotel.
“Shortly after 10.20am later that morning the infant was found deceased and still seated in the upright car seat. Despite a subsequent forensic post mortem, it was not possible to ascertain the cause of death.”
The baby’s parents were known to borough authorities and were both said to have alcohol misuse issues.
The child’s father had previously served a 30-month jail sentence for robbery and ‘it was known that mother found it difficult to keep track of him and he would go missing for days at a time, sometimes on drinking binges.’
And, at the time of Child M’s death in July 2016, the family were subject to Section 17 intervention – which defines a child as being ‘in need’ – due to concerns about maternal alcohol use.
According to the report, the family – including three primary school age children, a 13-month old and 10-week old twins – had travelled to a resort 35 miles from Wigan for the holiday.
The report states: “Child M’s death occurred in the morning, following the second night of the family’s holiday.
“The three youngest children were settled for the night in the attic bedroom anytime between 7pm and 7.30pm the previous evening.
“The twin infants were placed to sleep in their car seats which were upright on the bottom bunk bed.
“The parents had planned to use a sleep system which included carry cots, but this was reported to be too heavy to carry up the three sets of stairs to the attic room.”
The parents and the three older children had gone downstairs to the hotel lounge to ‘socialise’ but were said to have checked on the younger children every 30 minutes.
Some of these checks were verified by the police through a review of the hotel’s CCTV.
They said they had returned to their room around 1am and Child M was fed by her mother at 2.30am.
According to the report, the hotelier said the parents were ‘not excessively intoxicated’ the previous evening.
The following morning, after the discovery of Child M’s death, officers secured the hotel room as a possible crime scene and it was noted that empty cans of lager and beer bottles were present.
Following a police investigation, no charges were made and the parents participated in the review.
Although it found that some areas of multi-agency practice needed to be strengthened, there had been no ‘serious omissions’ in the lead up to the tragedy.
The report added: “The review has not identified any serious omission in practice that contributed to the death of Child M.
“The parents could not follow through on the plans to ensure Child M could sleep safely in the hotel and made the choice to place Child M to sleep in a car seat.
“This is one of the most significant risk factors in sudden infant death.”
The report highlighted that ‘all the professionals involved observed mother to have a positive relationship with her children.’
And it added that the father had expressed a desire ‘to turn his life around’.
The remaining four children live with their parents.
Dr Paul Kingston, Independent Chair Wigan Safeguarding Children Board, said: “This is a truly sad loss of a child and we send our continuing deepest condolences to the family.
“The findings highlight the difficulties faced by families in sustaining safe sleep arrangements, amidst gaps in cohesive professional advice from many sources, not least in relation to sleeping in car carry seats which is not a unique issue to Wigan.
“The commitment of the services that supported the child and family in the years preceding the child’s death was unquestionable, and the reviewers have identified many examples of good practice by professionals in providing information and support.
“There are many themes drawn out in the review where the systems that work together safeguarding children may be improved regarding inter-agency communication and information sharing, improvements that can be made to the pre-birth support process and the need for a whole family approach at all times by all agencies.
“As the WSCB Independent Chair, I have seen evidence of the Partnership already taking action on many of the issues identified in this Serious Case Review and this will be closely monitored to ensure that the changes make a positive difference to the children and families in the borough.”
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