How to reduce the risk of something like this happening again


A serious case review following the death of the eight-week-old baby in Crowborough has recommended better cross-border links between social care teams and the need for persistence and tenacity in professionals to ensure a child and carers are seen in person where they are believed to be vulnerable.

The report highlights that the family received a wide range of support from health services and local authority social care teams, but this, ultimately, had not prevented the death of the child.

The independent chair of the East Sussex Safeguarding Children Partnership (ESCPP), Reg Hooke, said:

This tragic and untimely death of a very young and vulnerable child inevitably required a serious case review to understand whether anything more could have been done to protect such vulnerable babies. In this case we had a particular focus on the health and social care services. The aim has been to reduce the risk of something like this happening again.

Reg Hooke, Chair of the East Sussex Safeguarding Children Partnership

The child’s father has subsequently been convicted of her murder, and her mother of allowing her death. Eight-week-old Holly Roe had suffered brain injuries at least three times leading up to her death in September 2018. Holly’s mother, Tiffany Tate was only 19 when Holly was born two months premature, and she had only recently left care. Michael Roe will serve a minimum of 19 years for murdering his baby daughter. Tate, has been jailed for two years and nine months for allowing her death.

The review report, which examined the contact and support the family had with various agencies, has been published now that the criminal process has been concluded.

Mr Hooke said one key aspect was that both parents had, as children, been in care. The review had highlighted the importance of local authorities continuing to offer support as a “corporate grandparent” when children leave care and have children themselves.

He added:

A good level of support was provided to the mother during pregnancy and post birth by the local authority and this case underlines for me the need for care leavers who become parents themselves to receive ongoing support in the same way many new parents benefit from the support of their own families.

Reg Hooke, Chair of the East Sussex Safeguarding Children Partnership

The report also recommends that hospitals should make sure a discharge planning meeting is always held after a child’s birth to ensure that the right support is in place straight-away.

The ESCPP has also said post-mortems should be conducted as soon as practicable where a child dies in such circumstances, and that CAT scans should be considered immediately when there’s an unexpected infant death. The Government’s Department of Health & Social Care has been asked to review capacity across the country in order to achieve this.

The report also found there had been no additional teenage pregnancy support for the child’s mother in the area she lived, and the fact that the mother had four midwives in a very short space of time because of capacity issues had created a challenging situation.

These very sad events took place some time ago and, although we’ve not been able to publish the report before now, we have been working closely with all the agencies involved . I am very pleased to say that the lessons this report identifies have either been or are being addressed.

Reg Hooke, Chair of the East Sussex Safeguarding Children Partnership

Click to download a copy of the Serious Case Review.



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