Public services have been asked to share more information following a review into the death of a baby who drowned in a bath.

The boy was found unresponsive at an address in Hertfordshire in April 2017. Despite efforts to resuscitate him at hospital, he died an hour later.

A serious case review was commissioned by Hertfordshire Safeguarding Children’s Board after the death to establish what led to the child’s death and what lessons could be learned.

The report notes that an “oversight” from police meant “neglectful conditions” the children were living in were missed while housing providers stated it was “important” to be updated on safeguarding information. But monthly meetings do now take place between police and housing associations, and a large number of referrals in Hertfordshire have been made since 2015.

The report recommends “good communication” between GPs and maternity services after information relating to the mother’s mental health was not shared.

The report describes how the baby boy was sharing a bath with his one-year-old brother when their mother went away to look for clothing and prepare breakfast.

When she returned, her baby was lying in the bath.

The mother, who moved to the UK in 2002 from Southern Africa, had suffered three miscarriages between 2013 and 2014 before falling pregnant again in late 2014.

She gave birth to her first son at just 26 weeks in April 2015. When the baby was born, a referral was made to maternity services but details of her mental health history - she was detained under the Mental Health Act in 2003 - and previous pregnancies were not disclosed.

She fell pregnant six months later and again her past was not disclosed.

In October 2015, police were called to the family home following reports of a dispute. When they arrived, they found the father on the doorstep of the “flat upstairs” drunk. He assaulted the two officers and was arrested.

The officers noted there was “no food of decent quality” for the newborn baby and their home was “dirty and unhygienic”, but did not notify children’s services of their findings.

The second child was born in April 2016. No concerns were ever raised during visits to the home.

The mother took her children to Africa for several months but when she returned, her partner had lost his job and this is when the mother admitted “family conditions began to deteriorate’.

In January 2017, it was found she was around 22 weeks pregnant.

Then in April, emergency services were called to the new family home, which was in the same borough, to reports of a child in cardiac arrest, after the boy was found in the bath.

A police officer noted: “The house was in a neglectful condition. There was evidence of mould to windows and walls. In the kitchen there was an absence of any consumable food. It was dirty and unhygienic. One room had a bed and baby cot and it would appear that the mother slept here with her baby boy. The cot was full of clothes and other items and did not appear to be used for the baby to sleep in.”

The following day, a strategy discussion took place about the accommodation of the older sibling. A home visit by a rapid response nurse said the house and garden was an “unsafe environment” for children.

The report reveals that the children’s parents had been suffering financially.

The review accepts the drowning was a “tragic accident” and parents should be warned of the dangers of leaving young children unattended in the bath. A water safety leaflet is now given to all new mothers.

The parents did not face any criminal charges.

The report states the mother’s mental health history had no impact on her ability to be a parent but that more support could have been offered had her mental health history been shared with the maternity services.

Missed health appointments did not concern professionals because the family did attend some.

The family did receive some specialist care but the report says “no additional efforts were made to encourage engagement in services”.

During the review, the mother stated she would have “benefited” from a parenting course.

Recommendations were made when the report was published earlier this year.

It wants the safeguarding board to seek assurance from health providers and commissioners that GPs tell maternity services of any social and medical risk factors in pregnant women.

The board should also seek assurance from the police that their procedure for responding to any incident of domestic abuse ensures that all relevant information is shared with partner agencies.

The HSCB should also seek assurance from housing commissioners that their own staff and those of housing providers, in particular those who make home visits, receive suitable training in recognising and responding to concerns about vulnerable adults and children. This should take account of the needs of families with small children who fall into arrears.

A Hertfordshire County Council spokeswoman said: "Hertfordshire Safeguarding Children Partnership (HSCP) commission serious case reviews and ensure that a clear action plan is developed following any recommendations made. With regards to this specific report and the recommendations, these have been fully considered by HSCP and actions developed and undertaken."

Hertfordshire Constabulary was approached for comment.