The baby , known as Mary , had been born at Alder Hey Hospital in Liverpool , pictured , but died six months later with traces of cocaine in her stomach . A six-month-old baby died with traces of cocaine in her stomach despite her drug-user parents being reported to social services five times . Small amounts of painkiller and anti-depressant drugs were also found in the infant , known as Mary , who died suddenly in 2013 , after a lengthy stay in Alder Hey Children 's Hospital in Liverpool . Now a review released today has called for a host of lessons to be learned after several agencies fell short in sharing information that could have highlighted the baby 's vulnerability . According to a report , Mary 's family , who lived in Liverpool , were well-known to social services and had been reported five times amid concerns of alcohol abuse , domestic violence and child neglect . A school had also raised concerns about the way other children in the family were being brought up . Mary was the youngest child in a family of four children born to a mother aged 30 and a father aged 33 . At the time of her death , her siblings were one , eight and 10 . Her parents came to the attention of social care unit Careline five times between 2008 and 2012 . Mary 's siblings ' school had already raised concerns that the two eldest children were overweight , staying off school and left to look after their baby brother while their parents stayed in bed . Mary was born 12 weeks early at Alder Hey Children 's Hospital in January 2013 and was diagnosed with a number of medical conditions , including a heart murmur . She was kept in hospital for three months during which time there were 'several consecutive days ' in which she had no contact with her parents . After she was discharged from hospital and into her parents ' care , a number of community nurse follow-up visits were scheduled . But the nurse was unable to get access to the family despite visiting them three times in one week . A fourth visit was successful but later appointments were not kept . A day before Mary died in July 2013 , a health visitor went to the home but was stopped at the door . A post-mortem revealed the presence 'at very low levels ' of cocaine , tramadol and mirtazapine ( an anti-depressant ) in her stomach . Police also found empty beer cans , drugs and a syringe on the premises and her mother admitted to the police that she used cocaine and cannabis in the home . Because of a lack of evidence , a coroner ruled the cause of Mary ’ s death was 'unascertained ' as it was ruled the traces of drugs , which could have come from the environment or through resuscitation attempts , were not considered to have directly led to her death . A post-mortem revealed the presence of cocaine , pictured , at 'very low levels ' as well as tramadol and mirtazapine , an anti depressant ( file picture ) The report said : 'Whilst agencies had some concerns about the older children , they generally worked to single rather than multi-agency agendas and processes . 'There was some evidence of good informal liaisons such as between the school and the education welfare officer , or the school and school nurse , but generally the level of inter-agency communication required to support a family with four children was not achieved . 'Child Mary was a vulnerable child and a discussion between health professionals may well have highlighted important information about [ the mother ’ s ] history of not engaging with health services in respect of her children and the shared information may have led to further action . ' But Liverpool Safeguarding Children Board , which compiled the independent report , said it was impossible to tell if the death of baby Mary – not her real name – could have been avoided . Chairman Howard Cooper said : 'Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy . 'It can not be inferred that child Mary ’ s death was preventable , but there are lessons to be learned for all the agencies involved with this family about multi-agency working. ” . Mr Cooper said a number of recommendations had been made in the wake of the infant 's death to improve working relationships between agencies tasked with supporting vulnerable children and their families . The 10 findings made by the board included an assessment that the follow-up services by Mary ’ s hospital and community health services were “ ineffective ” for a vulnerable baby in the care of parents with a “ very poor history of co-operation ” . The panel also criticised the lack of a multi-agency system for monitoring missed medical appointments , resulting in “ potentially significant ” signs of neglect being missed .
Infant , known as Mary , was also found with two other drugs in her system . She was discharged from hospital despite her parents being drug users . The family from Liverpool were already well-known to local social services . They had been arrested for possession of heroin and cocaine before the baby's death.