A baby girl died in a suspected "overlaying" tragedy - when an adult is thought to have smothered her by rolling over in unsafe sleeping conditions.
The infant, who was less than nine weeks old, was "found lifeless in her parent's bed by father" on New Year's Day in 2018.
It was thought that the death was caused by an 'overlay', although the post-mortem examination was inconclusive, Yorkshire Live reports.
A Serious Case Review looking into the Kirklees tragedy has been published by Kirklees Safeguarding Children Board which noted that the baby's parents were known to local agencies for incidents of domestic abuse and the neglect of older siblings who were born in 2010, 2011 and 2014.
The review says: "While the circumstances of Child A's death are inconclusive, the post mortem found that sleeping arrangements for the child were unsafe and raised the possibility of parental overlay."
A Child in Need plan had been in place since June 2015, but in January 2016 there was a unanimous decision to close the plan.
Mum was recorded to have made "significant progress in meeting children's needs", although her engagement with services was 'sporadic'.
Dad was allowed to see the children but only under supervision, the report said. However, the report said he "appeared to be essentially living at the address."
During her pregnancy with 'Child A' - the report does not name the baby - mum denied a relationship with father, stating that her pregnancy was the result of a one-night stand.
She also denied any domestic abuse. The report noted that conditions at the council-owned property in Kirklees were poor.
The gas supply had been turned off at the request of the mum in October 2017. There was a lack of suitable beds for children and there was waste in the garden, as well as no gas supply.
Child A was also in an "unsafe sleeping environment."
The baby girl was found lifeless in bed early in the morning on New Year's Day 2018.
Earlier that morning police had been called to the property after the father had reported that his brother was drunk and refusing to leave the house.
Officers responded quickly, determined that no offences had been committed and removed the brother.
The report made 31 'learning points' in relation to the baby's death. The following points were raised:
- Care should be taken to ensure all professionals working with the family are invited to multiagency meetings
- Professionals working with all families should seek to deepen their understanding of domestic abuse, especially in relation to engaging perpetrators, the impact of coercive control on victims, the risk of contact arrangements and the short and long term effects of exposure to domestic abuse on children.
- Assessments should include the voice of the child, challenge parents when they offer conflicting accounts of events, respond to new and emerging information and be robustly challenged by managers through a supervision process.
- Where a family has been known to services at different levels of safeguarding intervention over a period of time care should be taken to understand historic concerns and explore whether these are still present alongside new concerns.
- In light of historic concerns regarding suitable sleeping arrangements for children, all agencies should consider how they can further support families to ensure that children have appropriate sleeping arrangements in place.
- Relevant housing providers should be routinely invited to multi-agency discussions around safeguarding children.
In a statement, Kirklees Safeguarding Children Partnership said: "Overlay can occur when a young child is co-sleeping with adults in the same bed, though it is important to note that this has not been fully established as the cause of Child A’s sad death.
"The purpose of any Safeguarding Practice Review – both locally and nationally – is to assess the way a family was supported and seek ways of developing future practice.
"This review highlighted areas of good practice and found a number of learning points. It did not identify any actions that could have been taken by professionals to prevent Child A’s death.
"We can confirm that the learning has already been taken forward as part of our commitment to ensuring children and families receive the best possible support from local agencies."
An executive summary said the review had not identified any actions that may have been taken by professionals to prevent Child A's death. It added: "At the time of writing this report no criminal charges had been brought against Child A's Mother or Father.
"Child A's siblings were subject to interim care orders and unlikely to return to their parent's care."
