HEALTH workers followed procedure when dealing with the heart-rending case of 11-month-old Kimberley Baker.

This is the message from the woman in charge of protecting the welfare of Swindon's youngsters.

Hilary Pitts said midwives and health visitors kept to protocol, despite failing to pick up on the baby's maltreatment.

She said staff cannot force parents into making their children available for routine examination and that they had no reason to think Kimberley was being starved to death as her siblings were in good health.

But Mrs Pitts admitted that recommendations made by the Swindon Local Safeguarding Children's Board would be taken on board and procedures tightened up to minimise the risk of further similarly tragic deaths.

Kimberley weighed just 4.6kg - the size of a six-week-old child when she died in April 2005.

She had been starved to death by her parents, Alison and Neil Baker.

The couple have since been given five-year jail terms after admitting her manslaughter.

Kimberley was last seen alive by health workers in September 2004, but died seven months later. She would have been three on Tuesday.

A serious case review into her death said there were a number of missed opportunities for Social Services to intervene and assess the situation.

It reported that it was of significant concern that a young child with a family background of feeding problems, maternal depression and incidents of domestic violence, was not seen by professionals between then and the time she died.

However, Mrs Pitts said staff had done all they could.

She said: "There was no indication that Kimberley was at risk.

"There was nothing to say hang on this family needs to be directed.' The family had been stable for a considerable period of time.

"At the time 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.

"From September we did not see the child, but if a family says the baby is asleep or the baby is with its father there is nothing we can do.

"We have no legal right to see the child unless we have grave concerns of mistreatment.

"We had no concerns with Kimberley because we had no evidence and the other children were well."

Mrs Pitts said the recommendations made to agencies in the wake of Kimberley's death would be fully implemented in less than two months' time.

She said agencies were paying particular attention to flagging up parents who declined access to their children and mothers who discharge themselves from hospital earlier than expected - as was the case with Alison Baker.

"We are going to look carefully at those two things, but I am mindful of the fact that we don't have a right of access by law," said Mrs Pitts.

"I think if you have a child that is dead, it is always a really tragic event.

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

"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."

Statutory six-month and 18-month health visitor check-ups were abolished five years ago. But Mrs Pitts said it was impossible to tell whether a six-month check-up would have saved Kimberley's life.

But she added that the procedures being put in place currently would tighten up the system.

"I think the practices we have put in place may help and we would expect things to be tighter," she said "But there is always the possibility that this could happen again."

However, Mrs Pitt said that if children are seen to be at risk, the authorities will step in.

She said: "If youngsters are at risk or their well-being is at risk then we can escalate that to a risk assessment and consider whether the child or children need to go on the child protection register or, in some cases, be taken into care.

"When the last visit to Kimberley's home took place the environment had deteriorated, but one of the children was seen having a nappy changed using good quality products.

"There was no evidence to suggest children were at risk. Had they been at risk the midwife would have intervened, together with Social Services."