Report reveals how warning signs were not shared about '˜ticking timebomb' Portsmouth mother who murdered her baby
Multiple agencies failed to share details of '˜early signs of neglect' in the family of a '˜ticking timebomb' mum who murdered her baby son after hiding her pregnancy.
A serious case review found that information about Jake Long’s parents, including details of alleged domestic abuse, were not widely shared between agencies.
He was born at home in Agincourt Road, Buckland, into his mother Nicola Brown’s pyjamas on December 1, 2014, after she concealed the pregnancy.
But the review found staff at Queen Alexandra Hospital ‘failed’ to ‘adequately convey’ concerns to children’s services leading to a delay in the assessment of the baby boy’s family.
Infant Jake, who suffered 17 broken ribs at the hands of his mother, was just 19 days old when she killed him in 2014. Midwives immediately raised concerns about the birth as she had taken no steps to prepare for his arrival.
Staff reported an ‘altercation’ – but witnessed no assault – between Nicola Brown and Jake’s father, Jason Brown, on a ward at QA.
The mother, referred to as Ms X in the report, had ‘blood on her face’ and the family was moved to a side room but security was not told.
The argument was reported to children’s services emergency duty team in the early hours of December 3 but the ‘context of the situation and its severity was not conveyed in the details,’ the review found.
Children’s services had recommended a community midwife assess the situation as a history of domestic violence with the parents was not then mentioned – and it was wrongly thought the family were not known to the service.
Hospital midwives were ‘unhappy’ and repeatedly contacted children’s services but with ‘piecemeal and fragmented’ information — before escalating the matter to the hospital’s safeguarding team on December 4.
A fuller report to children’s services, including details that Brown had refused to engage with a midwife assessment, her depression and domestic abuse history, led to a social worker being allocated on December 10. The review found midwives had used escalation to ‘good effect’.
Baby Jake died on December 19 after his mother called 999 saying he had stopped breathing.
The family had been assessed a year prior to his birth by children’s services after domestic incidents but the case was closed.
Tina Scarborough, deputy director quality and safeguarding at Portsmouth CCG, told The News: ‘All agencies did what they could at the time.
‘When you look at any of these cases there are always some best practices you could learn.
‘All agencies did everything they could and there was not a key point where they could have intervened and made a difference.’
In a statement, Portsmouth NHS Hospitals Trust’s chief nurse, Theresa Murphy said: ‘Whilst the independent serious case review did not identify any failings in our service provision, or any obvious opportunities to predict and therefore intervene in this case, there were some best practice recommendations to improve care for all children and their families.’
The review found when the mother and baby were visited at home eight times on dates between December 4 and 19, ‘nothing remarkable was noted’.
During this time ‘at no point was the imminent risk to the baby apparent’ and ‘professionals conducted their duties appropriately’, the review said.
An earlier social services assessment of the family in 2013 after a domestic incident resulted in ‘no further action’ but it lacked analysis and there was ‘missing information’ from police and the GP.
The report said support should have been put in place.
It added: ‘There were concerns about parental mental health, alcohol misuse and domestic abuse – sometimes known as the toxic trio.’
Details of domestic abuse incidents were not shared between agencies, the review said.
Outlining the ‘lessons learned’, the review found:
n Problems with information sharing between agencies about the parents’ ‘toxic trio’ of domestic abuse, mental health problems and alcohol misuse.
n ‘Early signs of neglect were not shared between professionals’.
n Targeted services were not offered to the family as police, children’s social care and the health visitor had ‘incomplete exchanges of information’.
n Hospital staff initially ‘failed to adequately convey’ risks about the concealed pregnancy, ‘leading to a delay in the assessment of the family’.
n Escalation processes ‘used to good effect in this case and this is to be commended’.
Speaking to The News, Portsmouth Safeguarding Children Board chair Dr Richard John, whose organisation commissioned the review, said he accepted its findings.
Dr John said: ‘When you look back to 2014 you could easily look back to say “I’ve got many concerns” but the thing for me is not looking back, it’s looking forward.
‘What would concern me if as chair of the board I was concerned that the level, the speed and the pace of that the changes that has been needed to be made, weren’t being made.
‘That’s not the case here.
‘We remain committed to the people of Portsmouth to say that the service they will produce will always be professional, committed, dedicated to keeping children safe and listening to the voice of the child, and as a group of professionals, constantly reviewing, scrutinising and challenging the way we work with the single outcome to keep children safe within Portsmouth.’
Brown, 44, is serving a life term with a minimum of 14 and a half years after being convicted of murder and two charges of causing grievous bodily harm, which she always denied, at a trial.
Her husband Jason Brown, 45, whom she married after the death of her son, was acquitted during a trial of causing or allowing the death.
Chief nurse Miss Murphy added: ‘The death of any child is desperately sad and shocking for everyone involved. When a child dies in circumstances like these it is essential that all organisations involved review their actions to identify any opportunities for learning to prevent recurrence.’