A baby girl died after being strapped into a car seat almost continuously for 15 hours in a hotel room on a family holiday.
The 10-week old girl, identified only as Child M, was considered to be “high risk” after needing to be resuscitated at birth and weighing just 920g.
The girl, was one of three of the couple’s children to die in the space of two years after two sets of twins were born “extremely prematurely” just 11 months apart.
Of the seven children the mum has given birth to since June 2015, only four have survived longer than 16 months.
Nick Lloyd, road safety manager for the Royal Society for the Prevention of Accidents (RoSPA), said that research shows almost all car seat deaths occur when the car seat is being used outside the vehicle.
He said: "RoSPA advice is that travel be minimised in the first few months of a baby's life, keeping journeys to a period of one hour or shorter.
"If the journey is longer than this, it is important to make regular stops.
"Avoid keeping a young baby in a seat for longer than 30 minutes."
An independent serious case review has been published by Wigan Safeguarding Children Board following the tragic death of the infant in July 2016.
The probe revealed how the parents had left three infants for a period of six hours while they went drinking on a family holiday, checking in on them on “some” occasions.
The report contains 11 recommendations which, if applied at the time, may have prevented the infant’s “potentially predictable” death.
Authorities were aware that both parents had problems with alcohol, but early interventions were stood down because the mum “minimised” her issues and refused to give permission for help.
The tragic event unfolded on the third morning of the family’s four-day holiday, for which the parents had taken their six children to a resort just 35 miles from Wigan.
By this time, the family were known to the authorities due to a number of previous referrals to social services for concerns over the mum’s “alcohol misuse” and reports of potential domestic violence after she turned up at her job in a nursery with two black eyes.
Staff at A&E also reported the mum to social services after she turned up drunk at the hospital when she was 20 weeks pregnant with her first set of twins. Both the mum and the dad, a violent offender who had completed a 30-month jail stint for robbery just before the relationship started, were known to drug and alcohol services and social services.
At the time of Child M’s death, the dad was described as “unsupportive” and it was reported that he would often go off “for days at a time on drinking binges”.
Due to this reason, reviewers highlighted the need for various services to pay more attention to the “hidden male” in relationships when it is looking to safeguard children.
The holiday, which took place just weeks after the family’s fourth referral to social services, included three children - all primary-school age and younger, a 13-month-old child and the 10-week-old twins.
At around 10am the dad found his youngest daughter unresponsive in a baby car seat in the hotel room next to her twin sibling - who is the only child out of two sets of twins to survive past the age of 16 months.
Twenty minutes later the dad carried his lifeless infant down to the hotel reception where paramedics were called, arriving after just two minutes.
Paramedics noticed signs of rigor mortis, which sets in as soon as four hours after death, and the heartbreaking decision was made to “discontinue resuscitation”. She was pronounced dead at 11.23am.
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.
“Their sibling (aged 13 months) was placed to sleep in a bunk bed, although it was not known whether this was in the same room.
“Child M’s parents and their three older children then went downstairs to the hotel lounge to socialise and the parents were reported to have been checking on the three younger children on every 30 minutes.”
Police, who later carried out a criminal investigation, were able to verify that the parents had checked on their children on “some” of these occasions by reviewing the CCTV and speaking to the hotelier.
According to the parents, they returned to the bedroom at around 1am after drinking in the hotel bar, and Child M was fed by her mother at 2.30am.
Blood tests were taken from the parents after police found “empty cans of lager and beer bottles” in the bedroom. Concerns of “potential neglectful parental behaviour” were finally raised after they reported that the baby girl had only been fed three times in the 24 hours leading up to her death.
From the offset both sets of twins had health problems. Of the first set born in June 2015, one child died after three days and the other suffered from “complex needs”.
Child M was also considered to be “high risk” who needed to be resuscitated at birth and weighed just 920g.
She remained under the care of the Neo-Natal Outreach Team (NORT) who “worked with the family to prepare for their holiday”.
The group advised the family that there should be “no longer than five hours” between feeds - even if this meant waking the baby up to feed.
The following review into Child M’s death read: “This was a low number of feeds considering; the infant’s sub-optimum growth, gestational age and the feeding pattern was not thought to be in line with expert advice.”
NORT members also believed that the children would be sleeping in “carry cots”, but the parents did not follow through with this original plan as they were “too heavy” to carry up the three flights of stairs to the family bedroom.
Of the four referrals to child social care in a 10-year period, three were converted to “children and family assessments”.
Following one of these assessments the case was closed, and two were referred with recommendations of an “early help plan” and a “child in need” plan.
The reviewers stated: “Mother’s use of alcohol was a repeated focus of concern. There was some evidence that professionals attempted to work with the parents to assess their alcohol use.
“Father would seek support in respect of his alcohol behaviours and mental health challenges.
“Mother’s patterns of alcohol use were not well understood, and her disclosures of nil-alcohol were not always supported by professionals’ observervations or evidence.
“There were challenges for professionals in understanding how they could more effectively work with mother when they felt she minimised her alcohol use.”
At the time of Child M’s death, the family were already subject to a section 17 intervention, which defines a child as being “in need”, following a referral from the neonatal unit about maternal alcohol use.
Independent reviewers reported how, despite flagging up concerns that she did not have enough breast milk to feed Child M, the mum was told to “carry on as you are doing” by a midwife working with the family at the time - even though the baby girl was not gaining weight.
Another concern raised in the report, was that the parent’s choice of sleeping arrangement for their youngest children at the time of Child M’s death, was not “safe” for the infants.
The baby was already considered at “high risk” of sudden infant death syndrome, due to being a premature baby from a “multiple birth” in a household where her main caregivers smoked and drank.
“Professionals believed Child M’s parents understood the advice being offered in how to reduce the risk for Child M.
“This was evidenced by professionals observing where Child M was placed to sleep at home, parents smoking outside the home and agreeing that only one parent would consume alcohol if they were drinking.
“There were further professional discussions with parents to plan for safer sleep whilst on the holiday and new baby car seats were bought to ensure Child M and the twin sibling were transported safely.
“Whilst the review has identified areas of multi-agency practice that could be strengthened it 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.”
Depending on the source of information, parents are advised to remove their child from a car seat every 30 to 130 minutes to prevent sudden death.
As part of its recommendations, the Local Safeguarding Children Board (LSCB) has been told to “seek assurance” from the child death overview panel and Public Health that the current provision of safe sleep advice to families with SIDS risk factors have been review.
It has also been told to “encourage the Government” to regulate car seat hazard warnings so that parents can easily be informed of current guidelines.
No charges were brought following the police investigation and following an inquest, the coroner reported a narrative verdict, saying: “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 the 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”.
Reviewers said: “At times multi-agency partners worked cohesively together and were responsive to attendance at a range of safeguarding meetings.
“There was evidence of positive multi-agency communication and relationships, however there was also significant evidence of ‘silo working’ as the complexities for the family increased.”
Silo working refers to the mindset of organisations who do not wish to share information with other relevant parties.
The report found that although certain areas of multi-agency practice need to be bolstered, there were no “serious omissions in practice” which caused Child M’s death. 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 to safeguarding children may be improved regarding inter-agency communication and information sharing, improvements that can be made to pre-birth support process and the need for a whole family approach at all times by all agencies.”
All four surviving children still live with their parents.