Child Ollie Safeguarding Practice Review

The review was published on the 21st April 2023. The review centres on the tragic death of 9 week old baby Ollie who dies as a result of injuries accidentally sustained when co-sleeping with a parent on a sofa at home.

Analysis of Ollie’s urine revealed the presence of cocaine which was environmentally present in the house, and appears to have accidentally passed to Ollie via his dummy – many parents will put a dropped dummy in their mouth to clean it before putting it back in their babies mouth, anything present in the parents mouth will be passed to the baby. This highlights the very real dangers to children of recreational or casual drug use by parents in the family home. Even if the use of substances is kept away from the children, they may pick up substances in the home environment as well as having to live with the impact of the parental substance misuse.

The case highlights the absolute importance of having meaningful conversations with parents about safe sleep for babies and infants. There is learning for the safeguarding partnership about how those messages are delivered and understood and this will be explored in the reviews subsequent action plan.

This case also, as other cases has done,  identifies the importance for professionals to be professionally curious and challenging when necessary when poor home conditions or other indicators of neglect are visible. The use of the Graded Care Profile 2 is always recommended in cases where neglect may be known or suspected, and can often be a useful mechanism to identify areas of required support which may have otherwise gone unseen.

The case identifies the impact that the Covid-19 pandemic had on families and services and how services need to be away of the ongoing legacy of that for some of our most vulnerable families.

The report and learning poster are on our website:

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