Stacey Atkinson, 30, was given a suspended 12-month prison sentence at Liverpool Crown Court in October after pleading guilty to neglecting a child, causing unnecessary suffering or injury to health.
Ms Atkinson, of Marshalls Cross Lane in St Helens, fell asleep on her seven-week-old daughter Chloe Atkinson Wilkie on the evening of November 19, 2016, after drinking vodka until the early hours.
Her father, who had also been drinking, was asleep upstairs at the time.
Ms Atkinson, who has a history of alcohol and substance misuse, woke up on the couch around 6am the next day to find Chloe unconscious and unresponsive.
Chloe was confirmed dead an hour later at hospital.
A Serious Case Review, conducted by St Helens Local Safeguarding Children Board (LSCB), has revealed Ms Atkinson had a long history with various support services.
The report says that at least 13 contacts with Ms Atkinson were logged by children’s social care between 2009 and 2016.
No further action was taken on ten of those occasions.
The review highlights a number of “missed opportunities”, including a failure to refer Ms Atkinson for specialist support regarding alcohol misuse after she attended A&E in June 2014 following a three-day drinking binge.
The report says that in the ante-natal period, the lack of “management oversight and supervision” within maternity and mental health services resulted in “missed opportunities” to review the support provided, ensure a child focus, discuss mother’s limited engagement, consider other possible actions including early help support and challenge practitioner opinion.
It also reveals that a consultant psychiatrist attempted to make a child protection referral 11 days before Ms Atkinson gave birth to daughter Chloe, referred to as “Baby A” in the report.
Referrals are made when someone contacts children’s services because they have concerns about the safety and well-being of a child.
The psychiatrist believed there was a high risk of Ms Atkinson relapsing in the post-natal period, and was concerned this would lead to increased anxiety, self-harm and substance misuse and impact negatively on the care she could provide to Baby A.
However, the referral was not technically logged because the correct box had not been ticked.
The referral was de-escalated the day after Baby A’s birth to be managed by mental mealth, midwifery and health visiting services under the framework of early help.
The report, which was made available to the public this week, says that de-escalation process was “not managed effectively” by multi-agency partners, and said communication was “ineffective”.
The report says: “This was a missed opportunity to complete a formal social work assessment or to support understanding of the complex interrelating issues to manage the risk for the infant.”
Ms Atkinson was diagnosed with Bipolar disorder in 2011 and has a long history of mental health issues.
The report says she began smoking cannabis from the age of 12 years, with evidence of alcohol and cocaine use in her adult years.
The vulnerable mum, who has a history of self-harm, was regularly assessed to be a “heavy drinker” by GP services.
In November 2015 Ms Atkinson was referred to mental health services due to maternal increasing low mood, risk of self-harming and increased alcohol consumption.
Ms Atkinson had reported to GP and mental health services drinking up to a bottle of vodka and six to 10 pints of lager during any one session.
Despite this, key practitioners were not alerted to Ms Atkinson’s alcohol history after she became pregnant with Baby A, according to the report.
Ms Atkinson’s alcohol and substance misuse and mental health issues triggered a referral to the perinatal mental health midwife early on in her pregnancy.
An antenatal cause for concern form was then generated due to a “requirement for her unborn to be safeguarded”.
“This form is used to inform key practitioners involved in the provision care to mother and baby,” the report says.
“It included details of mother’s mental health history but not her alcohol disclosure.
“Therefore, key practitioners (community midwifery and health visitor) were not alerted to mother’s alcohol history.
“Midwifery services do not have a single record, this meant that the community midwifery service did not have access to the information regarding the mother’s alcohol history.”
Maternity services also failed to follow-up a missed appointment with Ms Atkinson’s midwife in the eighteenth week of her pregnancy.
This is despite a request being made for a review of her mental health just three weeks earlier.
Ms Atkinson was urgently referred to the perinatal mental health midwife in week 22 of her pregnancy after displaying “relapsing mental health symptoms”.
And on week 34 of her pregnancy Ms Atkinson attended a consultation with the recovery team psychiatrist, who advised her that a referral to children’s social care would be made to request an assessment of her needs.
The psychiatrist thought she had made a child protection referral, but this was not properly logged, according to the report.
The referral was screened the same day, but not prioritised for immediate assessment.
The case was closed the day after Ms Atkinson gave birth, with the decision documented as saying “midwifery report no concerns”.
One day after being discharged from hospital following the birth of Baby A, Ms Atkinson was visited by a support, time and recovery worker.
Ms Atkinson admitted that she had drunk alcohol the previous night while Baby A’s father had cared for her.
A week later Ms Atkinson told the community midwife that she had had a drink of alcohol for her birthday while Baby A was looked after by her father.
The report says: “These were two significant events in the post-natal period that could have alerted practitioners that Baby A’s mother was at risk of relapsing into the use of alcohol.
“However, the practitioners delivering care were not aware of Baby A’s mother’s alcohol misuse history and did not assess the disclosures to be of concern.
“They provided advice regarding the use of alcohol.
“During conversations, practitioners advised had they been fully aware of the maternal alcohol history this may have prompted further multiagency communications and planning to assess and manage the risk.”
In conclusion, the report says the risk “could have been predictable” had there been “robust multi-agency information sharing”.
The report says: “The review finds that there were complex, interacting factors leading up to the death of Baby A, as is frequently documented in infant deaths in similar circumstances.
“Within the timeline there was not one identifiable factor that led to the death or one point in the timeline at which, had different action been taken, the death could have been prevented.
“The risk could have been predictable had there been robust multi-agency information sharing to inform the risk assessment, planning and intervention in the antenatal and neonatal periods.”