Baby's death prompts coroner codeine concerns

A coroner has said clinicians were "insufficiently clear" on the dangers of codeine use after the death of a newborn baby.

Assistant coroner for Cumbria Robert Cohen said Isla McVeigh, who died one month after being born in June 2024, was found to be dependent on opiates because her mother was taking codeine.

Cohen said clinicians "agreed they had not sought to probe the nature of opiate use" and while Isla was in special care, "there were limited records of discussion of the use of opiates".

Cumberland Council, together with the Cumberland Safeguarding Children Partnership, said it had launched a review which would conclude in January to improve matters raised.

The North Cumbria Integrated Care NHS Foundation Trust (NCIC) said it actioned several processes including mandatory safeguarding, professional curiosity and opioid dependency briefings and the auditing of neonatal abstinence syndrome cases.

Isla was born with neonatal abstinence syndrome, which meant she had become dependent on opiates and required medical care to mitigate the symptoms of opiate withdrawal, a prevention of future deaths report said.

In hospital, staff raised concerns on several occasions when Isla was found being held by a person who was asleep, and so significant guidance was given as to safe sleeping, the coroner found.

Isla died on 25 July 2024.

The report said it was "more likely than not that she died of asphyxiation as a result of an unsafe sleeping environment" and it was "possible that the sedating effects of opiate use were a contributory factor".

The coroner determined 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", the report said.

The coroner's second matter of concern was how the nature of opiate use was the subject of "only very limited discussion", with Cohen finding there was "a lack of professional curiosity on this subject".

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 with authorities", the report read.

Cohen said: "I am concerned that this overstates and elevates the threshold of risk necessary to refer a child to children's services."

He said "unless action was taken to address the above concerns then there is a significant risk of future deaths".

Among several improvements, NCIC said it would review and update clinical guidance relating to the "management of pregnant women using prescribed and non-prescribed opioids" and would "enhance safeguarding supervision processes".

Meanwhile Cumberland Council and the Cumberland Safeguarding Children Partnership said its review would consider whether any current guidance could be interpreted as needing an "unnecessarily high" level of risk before referral.

The review would also consider whether existing guidance sufficiently supported practitioners to respond to cumulative risk, professional uncertainty and circumstances where early referral, consultation or assessment may be appropriate to safeguard children, it said.

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