Oct 15

SCR – Emily & Jack

Croydon Safeguarding Children Partnership (CSCP) is today (15th October 2020) publishing the Serious Case Review (SCR) of a three month old baby, Emily, who died in March 2019, and her older sibling, Jack.

Early on in her first pregnancy, Emily’s mother disclosed that she had a history of mental health issues and had required in-patient treatment in her home country. She was referred for perinatal mental health services, but was not offered a service as she was stable. She received routine ante-natal care and remained well throughout both pregnancies and births.

When Emily was 12 weeks old, her mother was taken by ambulance to Croydon University Hospital after alerting a neighbour that she had taken an overdose of Ibuprofen. She was discharged and advised to see the GP. A referral was made to children’s social services, who carried out a home visit and developed a plan, including a referral to the community mental health team.

A few days later, her husband called an ambulance after arriving home and finding Emily unresponsive.  Emily’s mother admitted killing her child and in July 2019, appeared in court and pleaded guilty to infanticide. She was convicted of this offence and given a Hospital Order under Section 37 Mental Health Act 1983.

Di Smith, independent chair of Croydon Safeguarding Children Partnership, said: “This was a tragic case of infanticide by a mother who was suffering from significant mental illness, with devastating consequences for the entire family.

It is not possible to say whether these tragic events could have been predicted or prevented had more professionals been aware of her mental health history. This review has however, highlighted issues with the way local agencies and health professionals share information; how patients can be enabled to feel safe in disclosing mental health issues and the possible impact of language and cultural barriers. It also raises some questions about the thresholds for perinatal mental health support, when a mother presents as stable but has a significant history of mental illness.

“All local agencies across the partnership have engaged with this review and fully support the findings. They will work together to develop a new alert system to inform practitioners where a patient has a history of mental health problems that have required in-patient treatment. Also, to ensure that practitioners are encouraged and supported to obtain information about a patient’s history from outside the UK where appropriate.”

You can download the full report here:

SCR Emily & Jack for publication v2

A single page briefing note is also available here:

Emily and Jack SCR Briefing June 2020 v2

NHS South London
Met Police
NHS Croydon Health Services
NHS Croydon Clinical
Safer London