Baby found 'emaciated' 19 days after social services closed case

An "incredibly emaciated" and starving baby, covered in sores, was taken to hospital in a critical condition 19 days after social services closed her case, a review has found.

The 19-month-old girl weighed 9.7lb (4.4kg) - less than half the 24lb (11kg) expected for an average child of her age - when she was treated in February 2025.

A Child Safeguarding Practice Review (CSPR) in Rochdale, Greater Manchester, reported the girl was severely dehydrated, had no fatty tissue noted on her body and had "paper-thin skin".

The case was closed despite warnings her mother, who was 17 when the baby was born, was neglecting her daughter and had avoided social workers and health visitors for weeks.

Rochdale Borough's Safeguarding Children Partnership said it accepted the findings of the review and was "taking action".

The CSPR, which referred to the girl as Child K1, said she displayed "skin breakdown" across the "entirety" of her bottom and nappy area.

Expert reviewer Nicki Walker-Hall said medics found "wasting to the buttocks" and open pressure sores extending along her back, hips and bottom.

She wrote: "Child K1's presentation of hypothermia, hypoglycaemia [low blood sugar], severe malnutrition, dehydration along with renal failure, evidenced by severe abnormality of blood salts, could have led to death if it had not been identified and emergency treatment initiated."

The review found the baby's mother had struggled with anxiety and low mood since the birth, and had been relying heavily on her own mother to care for the child.

Concerns were raised in April 2024 when the baby was taken to hospital by her grandmother due to refusing feeds overnight.

At that appointment another family member spoke to hospital staff and said the baby was being "neglected" by the mother, who she had witnessed lying asleep on a couch while her daughter cried alone upstairs.

The hospital made a referral to Rochdale's Children's Social Care team, who visited the mother and confirmed she was "willing to accept support".

Over the next few weeks early help workers were unable to contact the mother, although health visitors conducted visits and noted the baby's "basic needs" appeared to be met.

Walker-Hall said that changed in mid-December 2024, when an anonymous referral was made to Rochdale's Early Help and Safeguarding Hub (EHASH).

The tip-off described how the baby's hair was matted, she had a sore on her bottom, she was "leaking wax" from her ears, had thick cradle cap, long, dirty fingernails, was wearing dirty clothes and was underweight.

Social workers visited the house the same day and found the baby was indeed underweight and unkempt - but were unable to get the "upset" mother to consent to social care involvement.

"Numerous calls" were made between 7 January and 21 January 2025 to try and persuade her to change her mind and engage with a Child and Family Assessment but "these were unsuccessful", Walker-Hall wrote.

A multi-agency strategy meeting then took place, but it was decided due to a lack of information that the "threshold had not been met" to progress the case under Section 47 of the Children Act 1989.

That legislation requires a local authority to investigate if there is reasonable cause to suspect a child is suffering, or is likely to suffer, "significant harm".

The case was closed with no further action, despite Walker-Hall noting that the child had not been seen by a professional since mid-December.

The review identified a number of "learning points", including that practitioners needed to be "more curious" about the every-day experience of the child.

It said more should have been done to investigate who in the family was looking after the baby, which could have revealed to what extent the mother was "abdicating responsibility" and relying on her own mother.

Walker-Hall said the decision not to proceed to Section 47 due to only having partial information was "problematic".

A spokesperson for Rochdale Borough's Safeguarding Children Partnership told the BBC: "We accept the findings of the recent review and are taking action to ensure existing policies and procedures are followed by all professionals to ensure the safety of our children and young people."

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