Sorry, I must have missed that. But it makes more sense now. I know that removing a baby is only an option in cases of acute harm, or where a parent hasn't taken up the support of suggestions of social services . From my experience I have seen social workers do everything they can to try to keep a child with their parents, but the parent is just sometimes not in a place where they can accept this help, through no fault of their own, due to MH, adduction, DV or other past trauma. In my 20 years of work in paediatrics I have never seen a child removed where there was any other safe option for the child, in fact often as health professionals we feel they wait too long and give the birth parents too many second chances before removing. The 3 re unification I have seen, 2 of which were opposed by health professionals and did break down again and the children were removed again. So there is such a strong bias towards keeping children with or returning them to their parents
So she was offered help where she could stay with her child, but declined to take it up for fear of being watched. I fully get that it would have been uncomfortable for her, it would be for anyone, but its a huge shame she didn't give it a try. She might still be here now if she had. And she might not - we will never know.
And that's why the coroner didn't apportion blame. We don't know whether, even if she had got an advocate, whether that would have changed the outcome.
The only fact, is that this is incredibly sad loss of life, for the extended family, but especially for the baby. Who may wish to search for their birth mum when they turn 18, and they will find out that they will have no chance to get to know her.