ONE inquiry into the tragic drowning death of four-month-old Emma Jade Dyson - the third involving a baby under social services care in four years - has already revealed a catalogue of errors by care workers.

It showed that social services failed to support the family, that mother Robina's threats to harm her child were not acted upon, that health and social workers failed to pass on information to each other and that the mother and child were left on their own in the run-up to the tragedy.

Social services admitted then that Emma's family were left without a social worker - after she had been identified as being at risk - because the person working with the family had moved away.

One officer was said to have been "disciplined" and recommendations into changes of police and practices were said to have been acted upon but no-one lost their job for what the Community Health Council chairman Frank Clifford called "breathtaking incompetence and bungling."

Today we read a second shameful report.

This one is into the care - or lack of it - given to Emma's mother Robina Hashim whose mental illness problems led directly to her throwing her baby into the canal.

It shows that while social services were left wanting in safeguarding Emma herself the health services failed abysmally to treat Robina properly and take sufficient steps to ensure that those around her did not suffer because of her illness.

Six points are highlighted which could have prevented Emma's death and 14 recommendations are made.

It's often been said that treatment of mental illness is the Cinderella service in our health system because it isn't politically sexy.

That has got to change.

Once again today we have a bucketful of apologies and promises from those in charge. And they all say they are doing their utmost to make certain nothing like this happens again.

But once again no heads have rolled. That means no one has taken the ultimate responsibility for this death. They should have.