NOTHING could have been done to save a baby boy who died after being born in secret and was buried in a shoebox by his parents, a serious case review concludes.

In December 2017 Anthony Clark and Catherine Davies were each sentenced to 15 months in prison for concealing their four-day-old son’s birth and disposing of his body in Heaton Cemetery. The couple, of Thornbank East, Bolton, were cleared of murder on the direction of the judge.

Following the conclusion of the court case, Bolton Safeguarding Children Board commissioned a Serious Case Review to consider what lessons agencies could be learnt for the future.

The review panel’s report has now been published and lays bare the wretched, short life of the child, referred to as Baby C.

READ MORE: The tragedy behind Baby C's short life

“It is difficult to imagine how much Baby C must have suffered during such a short and tragic life. Baby C was unwanted, neglected and left to die by both parents,” states the report.

The couple had not even named the child, with Davies stating he did not need one.

Research shows that, although rare, concealment of pregnancy is associated with an increased likelihood of infant death.

Davies, identified only as MC in the report and Clark, referred to as FC, led a chaotic life, with both having personality disorders.

Clark was said to to be controlling and violent towards his partner, not allowing her to go out without him and she prioritised him before the child or a previous infant, who was taken into care and subsequently put up for adoption.

By the time Davies became pregnant with Baby C in early 2016 the pair had severed connections with various services.

Davies was not claiming benefits or working and was not registered with a GP practice. She did not seek ante-natal care and said that when Baby C was born, two to four weeks early, he would not take breast milk and Clark would not give her money to buy formula.

The child died, aged three to four days old, probably from dehydration.

The report concludes: “During the period of conception, pregnancy, birth and burial the review established that no professionals were actively involved or providing services to this couple.

“Therefore, there were no opportunities for practitioners to influence or change the outcome.”

The review was asked to look at what led Baby C’s parents to being so disengaged and “under the radar”, identifying preventative measures to reduce the likelihood of future concealed pregnancies.

But the only opportunity authorities had to possibly influence events with Baby C’s parents was when they were involved with them over the child’s older sibling, referred to as SC.

When the child was placed in foster care, despite the efforts of social workers and other agencies, Davies’ attachment to the child was said to be “poor”.

The report states: “There was an assumption, from all those working with MC, that she wanted to be a mother.

“On reflection, practitioners identified that MC was ambivalent in her attachment to SC. Practitioners should always be open to the possibility that a parent may need permission to verbalise a desire to relinquish their parental responsibilities.”

Davies and Clarke were said to have probably been “embarrassed and hurt and experienced a level of trauma” by the decision, taken out of their hands, to have their eldest child adopted.

The report focussed upon what support is available to parents whose birth child has been adopted and preventative work which could reduce the possibility of further pregnancies leading to adoption.

It states that Davies’ may have been helped with her attachment to her first child by the Family Nurse Partnership which now exists to give intensive support to new mums, but adds that the controlling nature of her relationship with Clark means it is unlikely.

At the time of SC’s adoption, post-adoption counselling for birth parents in Bolton was available but few people took up the offer and the report states that Davies and Clark are unlikely to have taken part.

The report expresses concern that there is no automatic system for informing health services about the vulnerability of birth parents after losing a child to adoption, adding that a letter to Davies’ GP at the time her eldest child was adopted my have made a difference to advice she was given.

Bolton Council and the CCG have accepted the recommendation that notification letters about adoption should be sent to birth parents’ GPs where the adoption was not agreed to by the parents and there is a possibility of a future pregnancy where the child may be at risk.

In their response to the recommendation, Bolton Council stated that it “would not be proportionate” for GPs to be informed of all adoptions as children are adopted for a variety of reasons.

From October 1 there will also be a new service, run by Family Action PACuk, focussed working with families to cope with the loss of a child through adoption.

However, all such services are not compulsory for parents and, such was Davies and Clark’s lack of interest in receiving support from agencies, they are unlikely to have wanted to engage.

“Neither MC nor FC was in a mindset that would have led them to seek support, “ states the report.

In response to the review’s report John Brimley, chairman of Bolton Safeguarding Children Board, said: “Any death of a child is a tragedy, but this a particularly shocking and upsetting case.

“On behalf of the Bolton Safeguarding Children Board I would like to offer my condolences to all those affected, and to express my sadness on the loss of such a young life.

“Cases like this are extremely rare, and this independent report looks closely to see if any opportunities were missed to offer the family support and guidance, and to protect Baby C.

“The independent reviewer has thoroughly reviewed the circumstances and has concluded that this death could not have been predicted or prevented, as both parents had completely disengaged from all support services for a significant period of time before the pregnancy, and did not seek support from services during the pregnancy, or after the birth. The mother was also not registered with a GP. This meant that any sort of intervention by any agency was impossible.

“At the time these sad events took place, a good level of support and advice was available to all birth parents in Bolton whose children had been adopted, but sadly these parents did not want to take up this offer. Since that time additional services have been also introduced, to further improve post-adoption support to parents. However, the independent report makes recommendations to strengthen the support offered, and all agencies involved in the review are developing services in response to those recommendations.

"This has been a very tragic and difficult case for all the individuals involved, and all agencies have engaged positively in this very important review. However, I would like to highlight the tenacity shown by Greater Manchester Police in conducting this investigation, without which we might never have known the details of this baby’s short and tragic life.”