Inquest into the death of A P

2y · Female·drowning

A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the child protection service had closed the case file prematurely in February 2015 despite known severe maternal mental illness and prior child removal; the community mental health team discharged the mother on 9 September despite her documented deterioration; and most significantly, an urgent referral from the treating GP on 9 September alerting the mental health emergency team to the mother's acute relapse was never actioned—no record was found and no clinical response was initiated. Had the referral been processed appropriately, immediate mental health intervention could have prevented the death. Systemic failures included poor inter-agency communication, inadequate supervision of junior staff, absence of psychiatrists from multidisciplinary team meetings, and lack of coordination between child protection and mental health services.