Portsmouth baby murder: 'Poor information sharing' before death
Poor information sharing between agencies meant warning signs were missed in the lead up to the murder of a 19-day-old baby by his mother, a serious case review has found.
Nicola Brown, 43, from Portsmouth, was found guilty of the murder of her son Jake following a trial in 2016.
The report said information between professionals, including hospital staff and GPs, was "left wanting".
This was particularly relevant in relation to Jake's parents' "histories", the report ordered by Portsmouth Safeguarding Children Board (PSCB) added.
Jake's father Jason Brown was acquitted of causing or allowing the death of a child.
The review claimed Mr Brown, named as Mr W in the report, had a "troubled childhood" and issues with excessive drinking.
Brown, named as Ms X, had behavioural difficulties as a child and was referred for anger management.
She also had a history of anxiety and depression, it said.
There were also reports of domestic abuse between the couple, with one altercation allegedly taking place in hospital the day after Jake, named as Child E, was born.
Brown's trial heard Jake died in December 2014 due to severe head injuries and previously suffered 17 broken ribs.
The jury was also told Brown had not informed her doctor she was expecting the child and social services were alerted to the "concealed pregnancy" after she gave birth at home.
The review found there was no record of any information being passed to the health visitor from children's social care or the police about alleged abuse within the couple's relationship.
An assessment of a report of domestic abuse was "hindered by missing information from the police and the GP", the report added.
Although information about alleged abuse was followed up by social services, an assessment "lacked analysis and relied heavily on the parents self-reports of the incidents without considering the experience of the child".
Brown's lack of antenatal care was referred to social services but that was "of poor quality and did not contain detailed information or the context of the situation".
"The lack of clear procedures in respect of concealed pregnancies was also a factor in the misunderstanding between the agencies," the report added.
The report said PSCB has worked to improve procedures concerning concealed pregnancies, including training for staff about the associated risks, since Jake's death
PSCB said other action taken in relation to a series of recommendations included all except one of its GP practices using the same electronic record system as health visitors.
It added it had also launched a new GP and midwife liaison form after an audit found the previous one was not being used regularly.