A CATALOGUE of errors and misjudgements which led to the death of a Burnley baby who was thrown into the canal by her mentally ill mother was revealed by health bosses today.

The independent report into the death of four-month-old Emma Jade Dyson prompted East Lancashire Health Authority and Lancashire social services to pledge to do all they could to prevent a repeat of the tragedy.

The independent inquiry into the case of Robina Hashim, commissioned by the East Lancashire Health Authority, identified failings in the care provided for the 30-year-old mother.

The Health Authority together with Burnley Healthcare Trust and Lancashire County Council Social Services, accepted conclusions and recommendations of the report.

As a result of criticisms a joint action plan has been developed.

A health watchdog described the treatment of a mentally ill mother who killed her baby as "a catalogue of failure at all levels".

The mother was sent to a secure mental unit after she admitted manslaughter on the grounds of diminished responsibility at Preston Crown Court last year.

The report into the medical care and treatment given to the mum highlighted six factors which could have prevented Emma's death:

In November/December 1999, Robina and Emma were not referred to the mother and baby unit at Withington Hospital, Manchester, which deals with mental health patients.

In December 1999 and after when Robina, of Clare Street, Burnley, was not prescribed sufficient medication to control her illness.

In March 2000 when Emma's father Stephen was not advised to stay at home.

On March 8, 2000 the day Robina's symptoms re-emerged when the community psychiatric nurse did not visit her.

On March 8, 2000 when Doctor Yasin, consultant psychiatrist at Burnley Healthcare Trust did not assess Robina personally and re-admit her to hospital.

Throughout, most of those caring for Robina did not read her notes.

The report said: "If they had they would have known her child assault history, they would not have treated the case as routine and they would have appreciated the dangers to Emma."

The report made 14 recommendations: 1 To develop a system that will link social services with mothers who are being treated for post-natal depression/puerperal psychosis; 2 No nurse should be appointed as named nurse to a patient until they are fully aware of the patient's condition and treatment; 3 All NHS staff required to attend pre-birth child protection conferences should receive sufficient training to ensure that they can make a contribution and when someone who can is unable to attend a deputy should represent him or her; 4 Junior doctors to present full history and treatment details of each patient on the ward to the consultants and the rest of the team at ward rounds or multi disciplinary meetings; 5 A review of ward 18, the mental health unit, at Burnley General Hospital from which Robina was discharged; 6 Increase the medical establishment in line with national guidelines; 7 Ensure that medical staff are involved with care programme and reviews and that all documents associated with the process are fully completed and received; 8 All staff should be managed and their practice monitored, measured and assessed; 9 Restrict the use of abbreviations, which have caused confusion; 10 Pre-birth child protection conferences should ideally take place between the 30th and 34th week of pregnancy; 11 Child protection conference notes should always state clearly the criteria and reasons for decisions and "children in need" plans should always be written in terms which identify clearly the tasks and outcomes required; 12 Where psychiatrict hospital admission has been decided in respect of a disturbed patient who has care or part care of a child and where there is history of child abuse arrangements should always be made for support to be provided until admission; 13 A review of the record keeping practices in social services; 14 Lancashire County Council to reconsider both their access to information practice and their information sharing practice.

The report said that Robina, whose husband Stephen left the country after the tragedy to start a new life, may have received more appropriate treatment had been better communication and liaison within and between the Mental Health Services provided by Burnley Healthcare NHS Trust and Social Services and there had been more discussion with Robina's partner Stephen.

Health bosses said it reassured all members of the families involved that lessons from this tragedy will improve procedures and practice in the future.

David Chew, Chief Executive of Burnley Healthcare NHS Trust said: "On behalf of the Trust I wish to reiterate the apology to the families concerned. There is no doubt with hindsight that there were shortcomings in the mental health services we provided. Robina Hashim had mental health problems which we failed to comprehensively assess and manage. It is also fair to say that communication and record-keeping was not of a sufficiently high standard in respect of this patient.

"We owe it to staff and patients to ensure that the very many professional and highly skilled people who deliver mental health care in East Lancashire are supported. However, we acknowledge the need to learn from our mistakes to enable us to continually improve services and provide the care people need and reasonably expect."

Mr Chew adds that recent investments will ensure that mistakes or errors are examined in close detail and everything possible is done to avoid any future recurrence.

Pauline Oliver, director of Social Services at Lancashire County Council said the report represented a tragic reminder for front line and managerial staff of the importance of continuing attention to good communications.

She said: "There is a determination among health and social services staff to use the findings of this inquiry in a constructive way to improve care for patients and their families."

David Peat, Chief Executive of East Lancashire Health Authority, which commissioned the report, acknowledged that there had been shortcomings. He said: "We take the report extremely seriously and we are urgently acting on all its recommendations. We are determined that everything possible will be done to avoid anything like this happening again."