THE woman responsible for child safety in the town says she cannot guarantee there will never be another case like Kimberley Baker's.

Hilary Pitts, the chairwoman of the Local Safeguarding Children's Board, was speaking after a report was published into the 11-month-old's death in April 2005.

Kimberley died after being starved to death by her parents, Neil and Alison Baker, of Hunsdon Close, Walcot.

She would have been three on Tuesday.

She weighed just 4.6kg when she died - the average weight of a six-week-old baby Her parents were jailed for five years in March after admitting the manslaughter of their baby daughter.

As reported in the Advertiser at the time in court Kimberley was described as looking like a famine-ravished Third World child.

But a serious case review carried out by the Swindon Local Safeguarding Children's Board catalogued a number of key issues in the aftermath of the baby's death.

The 16-page review outlines 20 recommendations to the agencies that dealt with the family, including Social Services and Swindon and Marlborough NHS Trust.

It says there were a number of missed opportunities for Social Services to intervene and assess the situation.

Kimberley was last seen alive by health workers in September 2004, when she was doing well. She died just seven months later.

The review said: "It is of significant concern that such a young child, with a family background of feeding problems, maternal depression and domestic violence incidents, was not seen by any professionals between then and the time she died."

The review also shows how concerns of the health visitor, probation officer, GPs and hospital doctors were noted, reported and passed on to each other informally but not followed up.

Had they been, the report says, it would have had the effect of highlighting the collected concerns of the professionals who were involved and also raising the profile of the case.

The review shows there was also uncertainty over who should take the lead in co-ordinating the concerns when they arose.

There were occasions in 2001 and 2002 when neighbours reported worries about the children to the police and health professionals.

It was in April 2002 that a health visitor expressed grave concerns about the family to Social Services.

But it was six months before the first and only visit from a social worker.

Then no interventions were made beyond support for a housing application and help for the mother to get more rest, the review said.

The review also pointed to the fact that the focus was on the mother's and children's health rather than identifying child protection concerns.

In April 2005, the month of Kimberley's death, a health visitor found the home was dark, smelly and sparsely furnished.

Kimberley died before discussions with the family about a referral to the Local Preventative Group were due to take place.

But Mrs Pitts said that while the health visitor noted issues about the environment the children were living in, she had no reason to think that the Bakers' five children were being neglected.

She added that the last time Kimberley had been seen by the health visitor during the statutory six to eight- week period after her birth, she had been well.

She said: "Kimberley was last seen in September 2004, that was at a time when all youngsters need to be seen and assessed.

"After that the family normally takes the youngster to the clinic or to the GP for a review.

"In this case health colleagues went to the house to actually help in that process to ensure the family was supported.

"At the time when Kimberley was seen in September she was doing well. She was at her normal developmental stage.

"There were no concerns at that time in relation to the health of Kimberley. She was not on the child protection register."

Mrs Pitts said that further visits to the house to see Kimberley had also failed to raise alarm bells, despite the fact her parents said she was not available to be examined.

She said health visitors had no legal right to demand to see children if there was no evidence to support maltreatment.

Speaking with regard to the serious case review's 20 recommendations, Mrs Pitts said all of the guidelines would be implemented in less than two months' time.

She said parents' declining access to their children by health workers would be flagged up in future, as would instances where mothers discharge themselves from hospital earlier than is recommended, as in the case of Alison Baker.

"It is difficult to think any system is perfect, but I think the procedures and practices were in place," she said.

"I think this is a particularly difficult case because of the lack of evidence indicating that Kimberley was in any way at risk.

"We are looking carefully at how we respond in future when we have no access to youngsters. On the other hand, at six to eight weeks Kimberley was fine.

"I think the practices we have put in place may help and we would expect things to be tighter.

"But there is always the possibility that this could happen again."

Recommendations that could save a life

The report recommends that all agencies should get training in identifying indicators of neglect and have a shared threshold level for intervention.

There should be a specific training for supervising staff in child protection for line managers and there should be a multi-agency protocol for visits which result in no access.

Children's case files should have a properly maintained chronology of significant events.

When working with a parent with mental health issues staff should assess its implications for children in the family.

Ambulance crew, particularly new technicians, potentially affected by follow up calls should to be offered counselling.

Wiltshire Ambulance Trust staff should undergo child protection and vulnerable children training.

The Walcot Family Centre should liaise with the referrer on the closure of a case to ensure a plan is in place to promote the welfare and safety of the child.

Wiltshire Constabulary should forward incident reports to Social Services, record if the child/children are seen and their welfare is assessed.

Social Services should take the context of the family history into account when considering the threshold for doing an in initial assessment.

Social Services should gather appropriate background information to inform the assessment process when concerns are raised about vulnerable families.

If the parent is seen as vulnerable, particularly in relation to mental health issues, this should be communicated to the Primary Health Care team and other professionals.

There should be additional training for GPs as clinicians in parenting capacity and the impact of parental mental health on parenting capacity.

Swindon Primary Care Trust should ensure that a lead professional is identified when more than one trust is concerned about a child.

The Swindon and Marlborough NHS Trust should have a policy for dealing with failed appointments and consider whether a referral should then be made to Social Services.

The trust should also notify the relevant professionals if a parent discharges themselves from hospital against medical advice at a risk to a child.

The trust should ensure that significant information is read and logged and action taken.