Death of baby boy smothered by his mother 'could have been prevented' The report found Katy Norris was 'passed from one mental health team to another', but no individual took responsibility for her. Photograph: Graeme Robertson/Getty Images Health professionals could have prevented the death of a 10-day-old baby who was smothered by his severely depressed mother, an independent inquiry has concluded (pdf). Teacher Katy Norris, who had a long history of mental illness, used a cushion to smother her newborn son, Leo, at their home in Devon. An investigation found that before Leo's death, Norris was seen by four mental health experts, two GPs, at least seven midwives or maternity care assistants, a consultant obstetrician, a health visitor and a nurse practitioner. The investigation concluded she was "passed from one mental health team to another because of concern about the severity of her mental health problems." But no one individual took responsibility for the co-ordination of her care. It judged there was no evidence any of the staff involved in her care considered themselves to be "professionally accountable for their responsibility for the safeguarding" of baby Leo. In addition, the investigation flagged up worries about how staff reacted after relatives of Norris raised concerns with health professionals. It found there was a "lack of timely and assertive intervention" in Norris' condition "despite the recognition that her mental health needs were complex and severe." The investigation concluded: "The death of Baby Y [Leo] was preventable." It added: "This case illustrates the problems that are encountered when assessment, monitoring, care planning and communication fail." Norris had a history of mental illness and in 1998, when she was 19, tried to kill herself by taking drugs and alcohol. She was prescribed antidepressants. During her pregnancy she initially stopped taking her drugs but began again when she found she could not cope without them. She gave birth to Leo on 10 April 2010. On 19 April her mother was alarmed that Norris did not seem to be bonding with the child and was smashing possessions up in her flat. The next day her mother-in-law went to Norris's flat in Brixham, south Devon, and found the baby apparently lifeless with a pillow over his head. Norris was lying next to the child. Norris was convicted of smothering the child while the balance of her mind was disturbed and was ordered to be detained in a mental health hospital. Alison Moores, the director of nursing and practice at Devon partnership NHS trust, said on Tuesday it was "one of the most tragic cases we have seen in the south-west." She said: "What is clear from both reports is that, in the weeks leading up to the incident, there were a number of missed opportunities to identify the risks, to respond to them appropriately and to ensure that a joined-up approach was taken to providing the necessary support and safeguarding action. The result was the tragic death of a baby which, the independent investigation report finds, was preventable. Since this death occurred, a number of very important changes have been made. Foremost amongst these is the system-wide development of robust child safeguarding arrangements right across the county. Three years ago, these were in the early stages of development but we now have clear, rigorous systems in place which involve representation from health, social care, local authorities and the police. Moores said the trust had also established specialist perinatal mental health teams that work jointly with acute hospitals and liaise with GPs, health visitors and children's services.