'We could have done more to help'

An investigation has found that 19-month-old Sadie's "needs, safety and well-being, particularly in relation to her mother's drug-use, could have been addressed more thoroughly" with better communication between agencies.

However, the North Yorkshire Area Child Protection Committee, which launched the review following the overdose in March, 2004, concluded that "no one agency could have predicted or prevented the death of Sadie".

After Sadie died on March 11, 2004, a Home Office post- mortem examination found no injuries or medical condition which could have contributed to her death. But toxicology tests indicated a potentially fatal ingestion of methadone.

On July 15, 2004, information from Forensic Science Services stated that tests on Sadie's hair had revealed evidence of probable sustained methadone presence over a period of months.

It was agreed on April 16, 2004, that a Serious Case Review should be undertaken into the circumstances of Sadie's death and practice issues. Sadie's mum, Fiona Milson, of High Hutton, near Malton, was sentenced to a two-year rehabilitation order at Leeds Crown Court after admitting manslaughter through gross negligence.

Now pregnant again, Fiona has yet to learn whether she will be able to keep her unborn child. Fiona told the Evening Press she welcomed any action which would prevent another death of an innocent child.

"Any substance misuse should be picked up as soon as possible when a child is involved. A child comes first. Parents have a choice when they take drugs. Children don't. I would hate for anyone to be devastated by going through what I have or for any child to suffer.

"I wasn't in touch with Social Services back then. You are given a lot of attention and support at the time when the baby is born and left to fend for yourself. The fact I was on methadone should have been given more attention and no-one was allocated to me, monitoring how I was doing. That's worrying."

Asked if Sadie should have been on the At Risk Register, she said: "If I could have prevented Sadie from dying, looking back now with hindsight, I would have done anything. If I could have worked with Social Services then and that could have prevented her death I would have."

The ACPC brings together police, North Yorkshire County Council social services, the Scarborough, Whitby and Ryedale Primary Care Trust and the local education authority.

A spokesman said: "The ACPC's responsibility is to ensure that any lessons learned from Sadie's death are identified and turned into actions for the protection of other children in North Yorkshire. There are many issues in this case, and in particular client confidentiality, which preclude the ACPC from commenting further."

After accepting the review findings, the ACPC has called for action mainly from Primary Care Trusts.

Among the work it deems essential is for trusts to ensure there are "clear protocols and sufficient expertise" for working with pregnant women and parents who abuse substances.

The report also highlights the need for North Yorkshire hospital trusts to explore and record a parent's substance misuse when it has been brought to their attention in Accident & Emergency or outpatient and when a child is admitted to a children's ward. The extent of the misuse and its impact on the child should be considered.

The PCT's director of public health, Dr Jeffrie Strang, said: "The summary of the Serious Case Review has just been issued today, and we need time to seriously consider the points that it makes. Once we have done this, we will discuss these points with the other members of the ACPC partnership, and take whatever action is necessary."

I needed better support says mum

"I would hate for anyone to be devastated by going through what I have, or for any child to suffer," said Fiona Milson as she welcomed calls for action to prevent other parents experiencing the tragic loss of a child.

Speaking to the Evening Press about the ACPC's review, she accepted her own responsibility for Sadie's death but admitted, in hindsight, that she would have welcomed outside support.

She supported the ACPC's calls for clear guidelines to be issued to midwives and health visitors to highlight the issue of safe storage of drugs throughout a child's life.

"Obviously I was aware that methadone was lethal for a child," she recalled. "It was always kept out of Sadie's way, apart from this one tragic time. Now we have a locked medicine cabinet to make sure nothing like this happens again. I would hate anyone else to go through this.

"I can't remember being given any significant advice about storing drugs. When you sign up at a drug agency they give you a lot of forms to read and sign, and that's that. You get bombarded with information. But nothing stands out."

She felt that safe storage of drugs should however be singled out as a priority.

Fiona, of High Hutton, near Malton, also backed calls for a nominated drug liaison midwife, and health visitors with specific expertise, to be appointed when dealing with substance-misuse parents.

"When I was pregnant last time I was in Leeds and I had a proper liaison mid-wife who looked after me all the way through. I felt totally relaxed with her. She didn't judge me. She totally understood what I was going through. She was aware of the issues surrounding being pregnant and taking a prescribed drug because I was on methadone at the time.

"There's nothing like that in North Yorkshire. I have been seeing a regular midwife. There doesn't seem to be anyone clued up on drug addiction.

"I agree that any substance misuse should be picked up as soon as possible when a child is involved. A child comes first. Parents have a choice when they take drugs. Children don't have a choice. I would hate for anyone to be devastated by going through what I have, or for any child to suffer."

Fiona also agreed that consistency with health visitors was also important.

"Back then I had a couple of different health visitors. Then you just get abandoned when the baby is between six and eight weeks. I was expecting them to come for longer.

"There was a huge lack of communication. Social Services have since interviewed my family and other people involved before Sadie's death. They (social services) said it was obvious there were problems".

On the subject of calls for PCTs to examine how they deal with cases of under-weight babies, she said: "The agencies have picked up on that since Sadie's death, saying she didn't put on any weight for months.

"At the time I was terrified she wasn't putting on weight. I took her to the doctor numerous times. I saw various locums, and mentioned it to them. I know she was faddy with her food at the time. They said it was probably because she was walking and more active. I thought that couldn't be right but no-one listened".

FIONA Elizabeth Milson was sentenced to a two-year community rehabilitation order at Leeds Crown Court after admitting responsibility for the death of her 19-month-old daughter, Sadie.

Milson, 33, of Almond Tree Avenue, Malton, admitted manslaughter on the basis of gross negligence before the Recorder of Leeds, Judge Norman Jones QC, in August.

Sadie died on March 11, 2004, due to poisoning with the heroin replacement drug methadone.

It was alleged in court that Sadie had been given a small amount of the drug on two previous occasions to stop her crying.

But on the night of Wednesday, March 10, it is thought Sadie managed to get hold of one of the methadone bottles and drank some of the contents.

Judge Norman Jones QC told Milson that her greatest punishment was her knowledge that she was responsible for her child's death.

He said the period of probation would allow pregnant Milson to receive help for her drug problem and he was confident she would be free of heroin by the time she gave birth.

Milson became addicted to heroin at the age of about 24 and has previous convictions for dishonesty and violence dating back to 1992.

On March 1, 1999, Milson was convicted of supplying heroin after she was spotted passing a wrap to a friend outside Marks & Spencers in York city centre.

She was found to be in possession of 17 wraps of heroin and a large amount of money and was put on probation for 12 months.

Milson has previously been in prison for up to four months but had not been before the courts during Sadie's short life.

:: Recommendations follow investigation

A NUMBER of recommendations have been made following the investigation into Sadie's tragedy. The include:

All PCTS must have clear protocols and sufficient expertise for working with pregnant women and parents who abuse substances, and appoint a drug liaison midwife and health visitor with specific expertise

Health staff must ensure all handwritten records are legible, dated and signed. PCTs should undertake regular audits to ensure these issues are addressed

PCTs should devise clear protocols for decisions and referrals to appropriate services where growth or weight gain is suboptimal

PCTs should ensure Primary Health Care Teams have effective methods of communication between GPs and other primary health care staff

North Yorkshire hospital trusts should explore and record a parent's substance misuse when it has been brought to their attention in Accident & Emergency, outpatients and when a child is admitted to a children's ward. The extent of the misuse and its impact on the child should be considered

Drug agencies should review staff training needs to ensure an understanding of the referral process.

They should also review guidelines for assessing risk when working with drug-using parents to ensure that safe storage of medication is addressed regularly during contact

Drug agencies should review staff training needs to ensure an understanding of the referral process.

Updated: 10:15 Tuesday, November 15, 2005