The review of the youngster’s death is the latest sparked by fatalities and injuries to babies aged under one in Sunderland in recent years.
Penny was born in August 2013 to a mum who already had two children who are looked after by their father after she suffered mental health problems while she was pregnant for the second time.
A host of support was set up for the 36-year-old when she discovered she was expecting again with her own mother dying in violent circumstances when she was 11.
The baby’s 51-year-old father’s history only became fully known after Penny’s death – he has a long history of convictions for violence and abused a former partner, was being treated for depression and known to mental health services.
The mother had refused to tell health and social workers who he was after they had a brief relationship, and when she finally told a health visitor, it was not shared.
The review states there was “considerable frustration from health professionals about the long delay in responses from children’s services” before the baby was born and the risks posed by Penny’s father were not looked at once he was known.
It says: “The high level of demand on children’s services became very apparent.
“The high turnover of staff and particularly managers was also a concern.”
Over a five-week period, a midwife was told the case had not been allocated before an officer then made contact, while the woman’s GP also struggled to get a response – all contact should be responded to within 24 hours.
The mum, who had been caring well for her daughter, had her case closed by mental health services following a turbulent period of arguments with the father in the time leading up to their child’s death.
On Monday, May 18, 2014, Penny fell in the bath while the woman went to answer the door and it was “likely she was not fully supervising Penny at the time of the incident”.
Both parents were present when the baby’s life support was switched off five days later.
Among the issues singled out in the report, the review states diminishing budgets and competing priorities, along with pressures, resulted in delays of several weeks by social services.