“The evidence I heard indicated that clinicians did not always understand the extent to…”

The coroner’s concerns

1) The evidence I heard indicated that clinicians did not always understand the extent to which codeine addiction might translate into the misuse of other opiates. It appeared to be the view of many that because codeine had been prescribed to Isla's mother, Isla's dependence upon it was not concerning. But this ignored the frequently encountered situation in which opiates are legitimately prescribed but still come to be abused. 2) Witnesses agreed that they had not sought to probe the nature of opiate use. Whilst Isla was in SCBU there were limited records of discussion of the use of opiates. The BadgerNet notes also show that this was the subject of only very limited discussion during pregnancy before Isla was delivered. I am concerned that there is a lack of professional curiosity on this subject. 11• 3) Safeguarding professionals' gave evidence that even if they had felt that Isla's mother was addicted to opiates they would not have considered that this met the threshold for escalation to Local Authority Children's Services because Cumberland Safeguarding Children Partnership's document 'Understanding the Level of Need and the Practice Response' provided that such a referral should only be made where a child is "at risk of significant harm or the needs are such that without intervention the child's health or development would be seriously impaired". They interpreted this to mean that in practice a referral would not have been accepted. They observed that, in their experience, the threshold for a successful referral was high. I am concerned that this overstates and elevates the threshold of risk necessary to refer a child to children's services. I am concerned that this gives rise to a risk of future death. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. All interested persons. 2. 3. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE Robert Cohen, HM Assistant Coroner for Cumbria

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0402

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14 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0