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Learning briefing: Ashton – Child death baby under 1

The incident

Ashton was born by caesarean section and due to post-delivery complications Mum was admitted to hospital leaving Ashton in the care of Dad. In the early hours of the morning, Dad called 999 and ambulance crew found Ashton unresponsive. Following an unsuccessful resuscitation attempt, his death was confirmed. Dad was believed to be under the influence of alcohol and/or drugs at the time he was caring for Ashton and he was arrested on suspicion of child cruelty offences. Dad has 2 other children who live with their mothers. They have limited contact with Dad. CAFCASS was involved with one of the children as access was being arranged through the family courts.

Reflection on practice

  • CAFCASS was the only agency who was aware of concerns raised about Dad’s parenting of his older child and that he was caring for a new baby. No concerns were picked up by midwifery, GP, or Public Health Nursing (PHN) services. The Family Court Adviser (FCA) should have considered the risk to the new baby and made a referral to MASH. This would have given agencies an opportunity to assess the risk and support the family during this difficult time.
  • Dad wasn’t present when the Health Visitor undertook the new birth visit, and their assessment was based on mum’s reporting. Dads are not routinely included in new birth visits. Services that are there to support children and families do not routinely engage with fathers.
  • Whilst Mum was an inpatient, Dad was verbally aggressive to hospital staff. This was not shared between ward staff, midwifery and PHN to enable an assessment of how parental distress might be impacting on their parenting capacity, and for support mechanisms to be identified and implemented.
  • Devon Doctors received a call from the parents concerned that Ashton had been waving their arms about and had hit themselves in the face and was unable to open their eyes. Ashton was brought to the emergency department but didn’t wait to be seen. This incident does not appear to have been communicated to PHN to assess Ashton’s health or consideration given that it was unusual mechanism of injury to cause trauma to an infant.
  • Devon Doctors were contacted by Dad with concerns that Mum was not coping well. She was described as aggressive and violent. As this was deemed to be 3rd party information, no action was taken. Consideration should have been given to sharing this information with the GP or PHN or signposting Dad to other professionals able to support them. This also could have included questions on how he was coping with reference to coping with a crying baby (ICON), safe sleep, and resources such as Dads Pad.

Good practice

Maternity services had conversations with both parents regarding safe sleeping and communicated well with Dad.


  • CAFCASS will ensure all staff are aware of the supervision process and criteria for reporting child protection concerns.
  • Devon Doctors will ensure all call handlers are aware of the criteria for information sharing and process for seeking supervision to aid decision making.
  • All staff working with parents need to consider the impact of emotional distress on a parent’s ability to care for their child.
  • All staff need to consider how they and their service engages with Dads so that they are able to assess their ability to parent, and receive support and information that will enable them to parent effectively


Further reading from National Review, The Myth of Invisible Men, is available on the government website.

If you are worried about the safety or wellbeing of a child or young person in Devon,
please complete the request for support online form.


If you think that the child is at risk of significant harm,
contact our Front Door directly by calling 0345 155 1071.


In an emergency call 999.