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2 October 2012, 15:38 | Updated: 2 October 2012, 17:28
An independent investigation into the death of a six week old baby has been published, and suggests more could have been done to prevent the death.
6 week-old Faith died in June 2009 after her mother Julia Lovemore, 41, tore out pages of the Bible and stuffed them into her mouth before smothering her.
Lovemore was detained indefinitely under the mental health act after admitting manslaughter on the grounds of diminished responsibility at Cambridge Crown Court.
An independent investigation into the care provided by the Cambridgeshire and Peterborough NHS Foundation Trust to Lovemore, who had been diagnosed with bipolar affective disorder, was published.
It concluded that confusion over Lovemore's "religious delusions" had distracted from the need to protect Faith and her sister, who was unharmed. The report added: "There was a failure to collectively recognise the extent to which this family were a risk to their children once they were mentally unwell, and to act more assertively to address their non-compliance with medication.''
Dr Chess Denman, medical director at the Cambridgeshire and Peterborough NHS Foundation Trust, said: "We have already responded to the recommendations of the Serious Case Review and our own thorough internal investigation.
We have made a wide range of improvements to our perinatal services, including appointing a perinatal consultant, and ongoing multi-agency training involving all partners across the system.
We have also improved the way we plan the care of our patients and focused all our staff on safeguarding through mandatory training."
Dr Denman added: "These not only address the areas of concern raised, they continue to increase awareness and understanding of perinatal mental health issues to all partners across the system.
We are now implementing a robust action plan in response to the external inquiry's findings, including reviewing our risk assessment process and further increasing our focus on quality and safety.''