A REPORT into the death of a baby in his mother’s bed has concluded it was “neither predictable nor preventable” by support agencies.

Amy Howell discovered her 11-month-old baby boy Teneil dead in her bed at the house in Deepdale Road, Breightmet, in December 2016. His inquest heard that he had died after being suffocated “by a sleeping adult.”

Following the death, a serious case review was carried out by Bolton Safeguarding and Children Board.

The review, led by Maureen Noble, looked into the actions of professionals supporting Miss Howell and what lessons can be learnt from the death.

The case review highlighted that professionals in Bolton were taking the time to impress on parents the importance of safe sleeping and the reviews shows Miss Howel was repeatedly told about the dangers of co-sleeping.

The case review also found that “information sharing between health agencies is hampered by the lack of a single system for recording, storing and sharing information across agencies.”

But it added this was “reflective of a national problem” with health information systems. John Brimley, independent chairman of Bolton Safeguarding Children Board, said: “I’d like to take this opportunity to offer my condolences to the family on behalf of the Bolton Safeguarding Children Board. Any sudden death of a child is a tragedy, which obviously has a devastating impact on the family and those close to them and this case is particularly distressing because it involved co-sleeping.

“Whilst the serious case review concluded that this death was neither predictable nor preventable, it reminds us all of the risks of co-sleeping.

“The Bolton Safeguarding Children Board has refreshed its ‘safe sleep’ campaign on several occasions since it was first launched in 2011 and aims to give the best advice on the safest place for babies to sleep, particularly in the first 12 months of their life. It is important that families know how to keep babies safe as nationally more than 270 infants a year die suddenly and unexpectedly due to co-sleeping or unsafe sleeping.

“This is almost four times the number of children who die as a consequence of abuse and neglect and more than four times the number of children aged 0-15 years who die every year as a consequence of road traffic incidents.

“I would urge all those caring for children aged 0-12 months to make themselves aware of, and follow, safe sleeping advice.”

The case review details the relationship Miss Howell had with her health care providers during her pregnancy and after Teneil was born.

According to the report, which was seen by Miss Howell prior to its publication, she was thought to be ‘capable’ of looking after her children but she ‘did not always take on board the advice given to her by professionals’.

The report notes that Miss Howell was a cannabis user and prior to and during her pregnancy she was taking anti depressants.

Ms Noble’s report notes Miss Howell made contact with all the correct agencies during her pregnancy and was open with her health visitor and GP about her cannabis use and mental health problems.

The report praises the relationships built up between the professionals and Miss Howell.

Ms Noble notes there were times professionals could have gone further, especially when consulting on Miss Howell’s “low mood”.

The report says: “She disclosed that she was having problems in her relationship but these were not explored further. “A proactive review of [the mother’s] treatment plan would be good practice, rather than reactive responses to requests for increased medication without further exploration of underlying factors.”

Regarding Miss Howell’s health visitor, the report says: “With regard to the disclosures of risk factors relating to drugs, alcohol and safe sleeping the health visitor was sure she had made the right decision in reminding the mother about risks and that this would be effective.

“It appears the health visitor erred on the side of optimism.”

The report issues recommendations to improve agency communication, to assess anxiety and depression management and training of practitioners.

It also recommends the “further development of local safe sleeping guidance based on the learning from this case” and this should include getting GPs to issue advice too, as requested by the coroner.