Authorities in Barking and Dagenham say they have made "significant changes" to strengthen procedures after a baby was shaken to death following "procedural and systemic shortfalls".

The Barking and Dagenham Safeguarding Children Partnership, which includes the council, police and NHS, has revealed it has undertaken improvements to its multi-agency work after producing a damning report earlier this year on the death of a baby boy in autumn 2018.

A serious case review into the death of the infant (referred to as Child F in the report) admitted agencies involved in the child's care made significant oversights. 

These included failures to properly support the birth mother (known as Ms X), who was 18 when she gave birth. 

Paramedics took the unresponsive body of the nine-month-old baby to hospital after the baby's mum reported that they had choked in the autumn of 2018, the review said.

The baby was taken to hospital where it was revealed that they had suffered a bleed on the brain and neurological issues consistent with shaking.

The injuries the child sustained left them unable to breathe without artificial ventilation and resulted in death, the report said.

A published review of the case by the partnership has concluded that "more could have been done" by professionals in events prior to the death. 

The review found that the vulnerability of the baby's mum and her history of experiencing violence at home had been "neglected".

The partnership wrote: "The likelihood of Ms X having difficulty in parenting and in keeping her own child safe was high considering her young age, her own childhood experience of neglectful care and of experiencing violence at home.

"Ms X was an extremely vulnerable young woman but despite her troubled history and her own poor experience of being parented, she and Child F did not receive the consistent, well-informed support they needed, and an over optimistic view was taken of how she was coping."

In February 2018, the baby's mum was referred to a perinatal mental health service by a GP after being "low in mood" but she failed to attend, the review found.

She was instead discharged without any risk assessment, it said.

Several instances in which professionals failed to accurately and thoroughly correspond with each other were flagged, according to the report, including an occasion where the baby was present during a fight. 

The review found that inconsistencies in a police report on the fight in December 2017, which involved the child's biological dad, were not taken up by the children's social care service. 

In their report, police made no mention to a hammer being present during the fight, despite this detail being included in a midwife's referral to social care.  

The partnership said: "Based on the police report, the children’s social care service did not regard the incident as serious enough for it to intervene having noted no mention of a hammer in the police notification so that it was assumed not to have been present."

Another failing, according to the review, saw the baby go six months without being seen by a health visitor, despite concerns over their head size. 

The review states that this was a result of demands on the service, staff sickness, increased client numbers and "highly vulnerable parents".

The matter was not followed up properly by GPs and clinic nurses who saw the baby, the review found, with long discussions being held as to who should have been investigating the matter. 

At the time of the infant's death, the review said concern did not appear to have been fully clinically assessed or explored. 

The partnership said: "This was a flawed response to what might have been a potentially urgent matter.

"From March 2018 to October 2018, the health visiting service was not in touch with Child F and Ms X.

"It is not clear therefore what sort of life experience Child F was having during those months prior to his death."

The report found that despite the issues raised, there was a "strong commitment" from those involved with the young family. 

The partnership wrote: "It was not foreseeable that Child F would be injured and die by anyone at the time, as it was believed that there was no evidence of any immediate risk to Child F, and that the range of service being provided would protect Child F.

"However, more could have been done to explore the vulnerability and risk for this family. 

"This review has identified some positives in the practice in the multi-agency partnership identifying and responding to risk to babies both before and after their birth.

"However, it has also identified some procedural and systemic shortfalls which should be addressed.

"It is very clear that all the professionals who were involved with Child F and the family did their utmost to help his parent to care for Child F and to keep Child F safe."

This paper contacted Barking and Dagenham Council for an update to see what changes had been made following the tragic incident. 

A spokesperson replied on behalf of the partnership and said that the purpose of such case reviews is to identify areas where local safeguarding partnerships need to learn and improve in. 

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They said: "Since 2018, safeguarding partners have made significant changes to strengthen key areas of multi-agency working relevant to this case, such as improvements to our Multi-Agency Safeguarding Hub (MASH), the creation of a dedicated ‘pre-birth’ social work team and the transformation of the partnerships’ Targeted Early Help Service and Family Hubs provision.

"Whilst the process of learning and improvement in relation to safeguarding children is never complete, the safeguarding partnership is satisfied that the key recommendations from this report have been worked on and those areas improved."

The partnership also said that a particular degree of learning and auditing is ongoing for it locally on matters relating to unseen men and family history, both of which were key areas of relevance to the case.