OPPORTUNITIES were missed to seek, and use information, about a mother known to authorities who caused the death of her three-year-old daughter in a drunken crash.

Findings of a serious case review by the Dorset Safeguarding Children Board into the death of Louisa May Pike have been published.

Alanda Pike, was driving with her daughter in the back seat when she crashed at Thickthorn Cross, north of Blandford, shortly before 7.50am on August 24, 2017.

Louisa suffered serious head injuries and died in hospital the following day.

At the time of the crash, Pike was more than three times over the limit for alcohol and cocaine derivatives in her blood and is now serving a custodial sentence.

Pike had a known history of alcohol dependency and had, over a number of years, been in contact with a range of agencies.

Pike disclosed to the Midwifery Service that she drank high amounts of alcohol before the pregnancy but said she was not drinking at the time. However, this was not explored

any further and no information was passed onto the GP or Health Visiting Service.

Six months prior to her daughter’s birth in 2014, Dorset Police stopped Pike whilst driving, finding her four times over the legal drink-drive limit.

In April 2016, Hampshire Police were called to a supermarket where Pike was seen to be heavily intoxicated, and had dropped her child.

The matter was immediately referred to Children’s Services where it was noted “an urgent assessment was required”, however 19 working days after the incident, the case was closed by Children’s Services as there had been ‘no corroborating evidence to support any ongoing risk to the child’.

The supermarket incident was also logged as a ‘domestic incident’ meaning the child safeguarding aspects were missed completely. Hampshire Police logs did not link to the Dorset Police log system – meaning information was missed.

In June 2016, October 2016 and March 2017, Pike again became known to a number of agencies for being intoxicated.

A review of the assessments conducted by Children’s Services revealed very limited information about Louisa’s father.

The report highlighted that the involvement of the father in the case would be “critical” as he would be in an ideal position to comment on whether Pike had been drinking or not.

At the end of June, a successful announced home visit was completed by a social worker. Pike denied drinking alcohol while caring for her daughter and Louisa was observed to be “happy, talkative and having a good bond with her mother”.

At the end of July, Children’s Services closed the case. Louisa died the following month.

The report reads: “In summary, the professional network was faced with pockets of information which was never determined to be at a level to warrant a more interventionist approach...Whilst the response of those agencies involved can be judged as reasonable, there is an opportunity to learn from this in order to strengthen future practice.”

'A tragic case'

Sarah Elliott, independent chairman of the Dorset Safeguarding Children Board said: “This is a tragic case and our deepest sympathy goes out to the family. Although different agencies had been involved with mother at different times, key links were not being made.

“It really does bring home the need for professionals to be curious and share information with one another, so they can consider the whole picture to help keep children safe. The aim of this review is to make sure professionals learn from events in order to prevent a similar tragedy from happening again.”

Missed opportunities highlighted included:

  • Opportunities were missed to seek, and use, information more effectively,

  • Both human and system errors contributed to information not always being sought and links not being made

  • Decision making and thresholds for intervention were clouded by information which was discrepant, or was unreliable or unsubstantiated

  • Pike disguised her alcohol dependency, concealing the impact on her lifestyle and any influence it might have had on her parenting ability,

  • The father was not included in any assessment work by agencies, and assumptions were made about him being a protective influence

  • It was assumed that the maternal grandparents were a protective factor in the child’s life, however, this was not explored appropriately

  • Some of the systems, processes and practice issues highlighted as deficits during the timeframe under review have improved i.e. the introduction of the Multi-Agency Safeguarding Hub (MASH), expectations of midwifery about gathering history