text: The baby, known as Mary, had been born at Alder Hey Hospital in Liverpool, pictured, but died six months later with traces of cocaine in her stomach . A six-month-old baby died with traces of cocaine in her stomach despite her drug-user parents being reported to social services five times. Small amounts of painkiller and anti-depressant drugs were also found in the infant, known as Mary, who died suddenly in 2013, after a lengthy stay in Alder Hey Children's Hospital in Liverpool. Now a review released today has called for a host of lessons to be learned after several agencies fell short in sharing information that could have highlighted the baby's vulnerability. According to a report, Mary's family, who lived in Liverpool, were well-known to social services and had been reported five times amid concerns of alcohol abuse, domestic violence and child neglect. A school had also raised concerns about the way other children in the family were being brought up. Mary was the youngest child in a family of four children born to a mother aged 30 and a father aged 33. At the time of her death, her siblings were one, eight and 10. Her parents came to the attention of social care unit Careline five times between 2008 and 2012. Mary's siblings' school had already raised concerns that the two eldest children were overweight, staying off school and left to look after their baby brother while their parents stayed in bed. Mary was born 12 weeks early at Alder Hey Children's Hospital in January 2013 and was diagnosed with a number of medical conditions, including a heart murmur. She was kept in hospital for three months during which time there were 'several consecutive days' in which she had no contact with her parents. After she was discharged from hospital and into her parents' care, a number of community nurse follow-up visits were scheduled. But the nurse was unable to get access to the family despite visiting them three times in one week. A fourth visit was successful but later appointments were not kept. A day before Mary died in July 2013, a health visitor went to the home but was stopped at the door. A post-mortem revealed the presence 'at very low levels' of cocaine, tramadol and mirtazapine (an anti-depressant) in her stomach. Police also found empty beer cans, drugs and a syringe on the premises and her mother admitted to the police that she used cocaine and cannabis in the home. Because of a lack of evidence, a coroner ruled the cause of Mary’s death was 'unascertained' as it was ruled the traces of drugs, which could have come from the environment or through resuscitation attempts, were not considered to have directly led to her death. A post-mortem revealed the presence of cocaine, pictured, at 'very low levels' as well as tramadol and mirtazapine, an anti depressant (file picture) The report said: 'Whilst agencies had some concerns about the older children, they generally worked to single rather than multi-agency agendas and processes. 'There was some evidence of good informal liaisons such as between the school and the education welfare officer, or the school and school nurse, but generally the level of inter-agency communication required to support a family with four children was not achieved. 'Child Mary was a vulnerable child and a discussion between health professionals may well have highlighted important information about [the mother’s] history of not engaging with health services in respect of her children and the shared information may have led to further action.' But Liverpool Safeguarding Children Board, which compiled the independent report, said it was impossible to tell if the death of baby Mary – not her real name – could have been avoided. Chairman Howard Cooper said: 'Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy. 'It cannot be inferred that child Mary’s death was preventable, but there are lessons to be learned for all the agencies involved with this family about multi-agency working.” Mr Cooper said a number of recommendations had been made in the wake of the infant's death to improve working relationships between agencies tasked with supporting vulnerable children and their families. The 10 findings made by the board included an assessment that the follow-up services by Mary’s hospital and community health services were “ineffective” for a vulnerable baby in the care of parents with a “very poor history of co-operation”. The panel also criticised the lack of a multi-agency system for monitoring missed medical appointments, resulting in “potentially significant” signs of neglect being missed.
target: Infant, known as Mary, was also found with two other drugs in her system .
  She was discharged from hospital despite her parents being drug users .
  The family from Liverpool were already well-known to local social services .
  Came amid concerns about alcohol abuse, domestic violence and neglect .