A coroner has labelled the lack of guidance as to how police and social care should respond to out of hours emergency situations as concerning and “ deeply disappointing”.
Assistant coroner Dr Elizabeth Didcock made the comments after giving a conclusion of unlawful killing in the case of a woman who killed her own daughter.
Seven-month-old Zoe Black was found dead in the undergrowth behind her home by neighbours on 1 September 2013.
The mother, Amy Black, had been taken home from London by police the day before, after she told them she had been trying to travel to Holland but had no passport.
Black is currently being detained indefinitely in a secure hospital.
Didcock rejected a Nottinghamshire social worker’s statement that police had failed to make a request for an urgent visit, according to BBC reports.
Sgt Ruby Barrow of the Nottinghamshire police told the inquest she had twice asked the social worker, Rohan Griffiths, to make an urgent visit to the mother and daughter.
She said the social worker had refused the request, saying there was no one on duty, but Griffiths denied any request for a visit had been made, according to BBC reports.
Dr Didcock rejected Griffiths’ evidence and said the lack of guidance as to how police and social care should jointly respond out of hours to emergency situations was concerning and “deeply disappointing.”
Independent chair of the Nottingham City Safeguarding Children Board, Paul Burnett said the full extent of Black’s metal health difficulties were not known by services at the time of baby Zoe’s death.
He said: “At the time she presented as a loving and attentive mother with no indication that she would intentionally harm her baby.
He said steps had now been taken to ensure an emergency duty team is available out of hours to deal with any concerns raised that a child is at imminent risk of significant harm.
“Had this been the case here, appropriate action would have been taken,” he said.
A serious case review has been carried out and is due to be published once the coroners’ findings have been considered.