Coroner raises concerns after death of Cumbria baby
Assistant coroner says action is needed to prevent future deaths
A Cumbria coroner has warned there is a significant risk of future deaths unless action is taken, after a baby who was born dependent on opiates was found dead at home.
Assistant coroner Robert Cohen has issued a Prevention of Future Deaths report following the inquest into the death of Isla Alma McVeigh.
Isla was born on 19th June 2024 and died just over a month later, on 25th July 2024.
The report has been sent to North Cumbria Integrated Care NHS Foundation Trust, Cumberland Council and the Cumberland Safeguarding Children Partnership.
What the inquest found
The report says Isla was born with Neonatal Abstinence Syndrome.
It says she became dependent on opiates before birth because her mother was taking codeine, and needed medical care to ease the symptoms of withdrawal.
She was admitted to hospital and treated with morphine.
She was discharged against medical advice on 2nd July 2024.
She was found dead at home on the morning of 25th July 2024, and her death was confirmed at 7.22am.
The medical cause of death was asphyxia.
The report says it is more likely than not that Isla died as a result of an unsafe sleeping environment.
It adds that it is possible the sedating effects of opiate use were a contributory factor.
The report says staff raised concerns on several occasions while Isla was in hospital after she was found being held by a person who was asleep, and significant guidance was given on safe sleeping.
It says it is not possible to determine whether the person who had been feeding Isla had used opiates, but that it is possible.
Isla was not referred to local authority children's services during her life.
The coroner's concerns
Mr Cohen set out three concerns in the report.
The first is that clinicians did not always understand how codeine addiction might lead to the misuse of other opiates.
The report says many appeared to believe Isla's dependence was not concerning because codeine had been prescribed to her mother.
Mr Cohen said this ignored the situation in which opiates are legitimately prescribed but still come to be abused.
The second concern is a lack of professional curiosity.
The report says witnesses agreed they had not sought to probe the nature of opiate use.
It says there were limited records of discussion about opiate use while Isla was in the special care baby unit, and only very limited discussion during the pregnancy.
Mr Cohen said: "I am concerned that there is a lack of professional curiosity on this subject."
The third concern is that the threshold for involving local authority children's services is too high in practice.
Safeguarding professionals told the inquest that even if they had thought Isla's mother was addicted to opiates, they would not have considered it enough to escalate to children's services.
They pointed to a Cumberland Safeguarding Children Partnership document, which says a referral should only be made where a child is "at risk of significant harm or the needs are such that without intervention the child's health or development would be seriously impaired".
They interpreted this to mean a referral would not have been accepted, and said the threshold for a successful referral was high in their experience.
Mr Cohen said: "I am concerned that this overstates and elevates the threshold of risk necessary to refer a child to children's services. I am concerned that this gives rise to a risk of future death."