PERFORMANCE: NHS Gloucestershire Care Services has introduced changes to protocols for its health visitor, mental health and substance misuse services following the death of a 14-month child.

A toxicology report found the child had died from an overdose of methadone. Tests on her sibling revealed they had also been given the heroin substitute on an infrequent basis.

A serious case review criticised communications between the different agencies involved with the family where both parents and the mother’s new partner were substance users and the father had a history of domestic violence. It found that although none of the professionals involved would have witnessed the children under the influence of methadone they had not sufficiently considered what the impact of the situation on the children.

NHS Gloucestershire Care Services, Gloucestershire Hospitals NHS Foundation Trust, 2gether NHS Foundation Trust, and Great Western Ambulance Service all submitted individual management reviews, as did Herefordshire PCT Drug Services, Herefordshire PCT Health Visiting Service, and Herefordshire Hospitals NHS Trust as the family had previously lived in Herefordshire.

A report to NHS Gloucestershire’s board revealed that actions taken as a result of lessons learned from the case include:

  • Within mental health services the services user information sharing, confidentiality and consent form has been amended to include permission to share information with the health visitor if there are children under school age living in the house or school nurse if they are of school age.
  • A safeguarding children risk assessment has been developed for the county’s substance misuse teams and a family health needs assessment has been introduced for the health visitor service.
  • Health visitor good practice benchmarks have been amended to include provision of advice on safe storage of medication and drugs and have been circulated to all health visitors.