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A premature baby died on the night his family were evicted from their home and after valuable support was withdrawn, a serious case review has found.

The report tells how ‘John’, a two-month old baby who was born six weeks prematurely, died after his parents and one-year-old sister were made homeless following eviction from their home in Warwickshire.

On the night they were evicted, in September 2013, John spent the night on his grandparents’ sofa with one of his parents. But when the family woke-up, John had died.

A coroner later recorded an open verdict over the death and the serious case review by Warwickshire Safeguarding Children Board showed there had been no mistreatment involved.

The review discovered the eviction had taken place after the social housing agency had withdrawn ‘tenancy support’ from the family. The service helps with issues such as finance management, but was withdrawn at the same time the family found themselves slipping into rent arrears.

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Findings in the serious case review showed that the agencies involved in the eviction of the family had not properly understood the potential consequences of the eviction. A wide-range of organisations were involved in the process including the council’s social services department, the housing association, NHS workers and the Citizen’s Advice Bureau.

It also acknowledged that agency responses were sometimes “superficial and do not always get to the heart of what the issues, and therefore do not fully address risk.”

There was also concern that information was not properly shared across agencies. The report added that not enough attention had been paid to the fact the mother was recovering from a cesarean section as well as dealing with her young daughter, who suffered from a developmental delay, and a premature baby.

Joanna Nicolas, independent author of the report released this week, said: “The agencies working with this family had not fully understood the issues at the heart of the case, and could have done more to mitigate the impact of the family’s eviction.

“The report also found that there was confusion about the extent of the lead professional’s role during the child’s assessment period.”

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Since the death of John, the housing association now holds internal case reviews before evictions to ensure all information is considered and ensure that children’s social care are notified following eviction of a family.

Further measures taken include training for health professionals, social workers and police officers. A multi-agency safeguarding hub (MASH) is also being developed and will support information sharing.

David Peplow, chair of Warwickshire Safeguarding Children Board, said: “This is a deeply saddening case and on behalf of the board we express our heartfelt sympathies to the family for the loss of their child.

“A number of agencies were in contact with the family and, although child protection issues were not a causative factor in John’s death, we feel that there is important learning for all agencies from this case.

“We want agencies both in Warwickshire and nationally to learn from this case and improve practice.”