Overview
- The inquest, which convened Wednesday at Swann House in Stoke, heard nurses found 10‑week‑old Phoebe‑Rose Douglas “unkempt and smelly” after paramedics rushed her from Blurton on October 25, 2019, following a cardiac arrest; she died four days later.
- Toxicology presented to the coroner showed a urine sample on October 29 contained cocaine, and hair analysis indicated exposure to cocaine, heroin and cannabis.
- A consultant pathologist told the hearing the baby’s brain was swollen in a way consistent with a lack of oxygen, with no significant external injuries, and he identified maternal drug use and smoking as the clearest risk factors.
- Records and testimony set out missed six‑to‑eight‑week GP checks and first immunisations, drug use by both parents, and multiple pre‑birth referrals to social services that preceded an eviction where drug paraphernalia was later found.
- Safeguarding leaders said a rapid review and a later thematic review identified weak early‑help assessment, unclear lead roles and an over‑reliance on families attending clinics, and they outlined changes since 2021 including closer adult‑children services, family hubs, more home visits and rollout of the Families First approach.