Probe into care of mother who smothered her child finds mental health safeguarding failings

An investigation into the mental health care provided to a mother who smothered her 10-day old son has concluded that the child’s death was preventable and identified a number of failings by NHS agencies.

Katy Norris had severe depression when she smothered Baby Leo, referred to as Baby Y in the investigators’ report, in April 2010. Norris admitted infanticide and a judge made a section 37 hospital order under the Mental Health Act.

In the three months leading up to the child’s death, Norris received mental health care from Devon Partnership NHS Trust. She also had treatment from the South Devon Healthcare Trust and the Torbay Care Trust.

An independent investigation into treatment provided to Norris by the three NHS bodies concluded that the death of Baby Y was preventable. It found that two “direct causal factors” connected care failings to the death of the child.

A lack of action by professionals to take “assertive and timely” action to address Norris’s depression had caused her “mental state to deteriorate to the point of killing” her child, the report found.

Professionals had also failed to identify the potential risk to Baby Y from his mother’s deteriorating mental health. As a result, they failed to trigger the safeguarding children procedure “in a timely manner” and “no inter-agency management plan was put in place to manage the risk” to the child.

A Devon Partnership NHS Trust spokesperson has apologised.

In March 2010, Norris – referred to in the report as Ms.X – had been subject to the Care Programme Approach (CPA) after an urgent referral.

The CPA policy is designed to boost coordinated care for people with severe and complex mental health needs. But, despite being allocated a care coordinator, opportunities to address the “uncoordinated care” offered to Norris had been missed, the report found.

“It is never a straight-forward task to make a direct causal link between an act or omission on the part of mental health care professionals and a homicide perpetrated by an independent third party,” the report said.

“However the Care Programme Approach is an evidence-based process which is widely accepted as being an effective method of ensuring the continued health, safety and wellbeing of service users and those around them.“

“In the case of Ms. X the most basic building blocks of the Care Programme Approach were not implemented and the independent investigation team concluded that this was to the ultimate detriment of the health, safety and wellbeing of both Ms. X and her baby.”

Alison Moores, Director of Nursing and Practice at Devon Partnership NHS Trust, said the trust accepted all of the findings in relation to care and treatment of Norris.

“This is one of the most tragic cases we have seen in the south west and I would like to offer my apologies and heartfelt sympathy to the family. 

“It has had a significant impact upon the staff concerned, and our organisation as a whole, and we take the report’s findings very seriously indeed,” said Moores.

Moores said that a number of “very important” changes had been made to improve coordinated care and safeguarding, since the death of Baby Y occurred. Enhanced safeguarding arrangements are now in place in the county, which involve representation from health, social care, local authorities and police.

The trust’s systems for planning and coordinating care have been reviewed and specialist perinatal mental health teams have been established in partnership with South Devon Healthcare NHS Foundation Trust.