Recurring concern

Unsafe breastfeeding arrangements exposing babies to suffocation risks

First to latest report 21 Aug 2018 — 12 Dec 2024

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 10

What this concern includes

Includes failures in guidance, advice or operational arrangements specifically governing the safe breastfeeding of babies, including positioning and airway protection in carriers or slings and advice or safeguards for breastfeeding in bed when the mother is fatigued or alone.

What is not included

Excludes general infant feeding, breastfeeding access or nutritional-support concerns where no suffocation or unsafe-positioning risk is identified.
Excludes safe-sleep concerns unrelated to breastfeeding, including ordinary sleep-environment, bedding or prone-sleeping risks.
Excludes isolated adverse outcomes where no continuing failure in breastfeeding-specific safety guidance or arrangements is asserted.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Bolton NHS Foundation Trust1

British Standards Institution1

Department of Health and Social Care1

NHS England1

Office for Product Safety and Standards1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

12 Dec2024
West London
Concerns raised1
1. Lack of guidance on breastfeeding young babies in carriers/slings
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

CAPT
Department of Health and Social Care
NCT
NHS England
Office for Product Safety and Standards
the Lullaby Trust
The Royal Society For The Prevention Of Accidents
Stated actions 8
1. Department of Health and Social Care
  Review the prominence of existing baby-carrier safety information on the Better Health – Start for Life website and in personalised emails.
2. Department of Health and Social Care
  Consider ways to supplement Better Health – Start for Life content about baby carriers and breastfeeding.
3. Department of Health and Social Care
  Engage key stakeholders, including UNICEF UK, to develop appropriate messaging about baby carriers and breastfeeding.
1. Department of Health and Social Care
  Work with NHS England to establish consistent guidance on sling use and breastfeeding.
2. CAPT and NCT and the Lullaby Trust and The Royal Society For The Prevention Of Accidents
  Develop revised parental guidance on hands-free breastfeeding using slings and carriers.
3. CAPT and NCT and the Lullaby Trust and The Royal Society For The Prevention Of Accidents
  Provide consistent messaging that hands-free breastfeeding using slings and carriers is unsafe and should not be attempted.
4. NHS England
  Work with the NHS.UK website team to make sling-safety guidance easier to find and link it to relevant breastfeeding information.
5. NHS England
  Refer safe sling-use advice for consideration in NICE guidance.
Respondent positions 4
1. Department of Health and Social Care
  Baby sling manufacturers are responsible for providing clear guidance on product suitability and safe use during breastfeeding.
  Redirects responsibility
1. Office for Product Safety and Standards
  The Department of Health and Social Care and NHS England are responsible for responding on baby-carrier and breastfeeding advice.
  Redirects responsibility
2. NHS England
  Product manufacturers bear significant responsibility for providing parents with adequate guidance on the safe use of newborn carriers and slings.
  Redirects responsibility
3. NHS England
  NICE is responsible for considering whether recommendations on safe sling use should be included in routine antenatal advice.
  Redirects responsibility
AI-generated summary

James Robert Michael ALDERMAN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on breastfeeding young babies in carriers/slings
Wider context from the report
“(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings (2) This notwithstanding a significant increase over recent years in the use of such equipment. (3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature. (4) The NHS available literature provides no guidance or advice. (5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful (6) Young babies are at risk of suffocation. (7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory. ”
Source location
James Robert Michael ALDERMAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the prominence of existing baby-carrier safety information on the Better Health – Start for Life website and in personalised emails.

Verbatim wording from the response
“Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.”

Source location
Response from DHSC
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider ways to supplement Better Health – Start for Life content about baby carriers and breastfeeding.

Verbatim wording from the response
“Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.”

Source location
Response from DHSC
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Engage key stakeholders, including UNICEF UK, to develop appropriate messaging about baby carriers and breastfeeding.

Verbatim wording from the response
“Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.”

Source location
Response from DHSC
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with NHS England to establish consistent guidance on sling use and breastfeeding.

Verbatim wording from the response
“Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.”

Source location
Response from DHSC
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop revised parental guidance on hands-free breastfeeding using slings and carriers.

Verbatim wording from the response
“We are now, together, looking to make rapid change to the guidance for parents around hands-free breastfeeding using slings and carriers, and have agreed that we will tell parents and families, consistently, that this is unsafe and should not be attempted. NCT have already updated their guidance (Baby slings and carriers: a guide | NCT) and I know other organisations here are committed to doing similar.”

Source location
Response from The Lullaby Trust
Page 1 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide consistent messaging that hands-free breastfeeding using slings and carriers is unsafe and should not be attempted.

Verbatim wording from the response
“We are now, together, looking to make rapid change to the guidance for parents around hands-free breastfeeding using slings and carriers, and have agreed that we will tell parents and families, consistently, that this is unsafe and should not be attempted. NCT have already updated their guidance (Baby slings and carriers: a guide | NCT) and I know other organisations here are committed to doing similar.”

Source location
Response from The Lullaby Trust
Page 1 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the NHS.UK website team to make sling-safety guidance easier to find and link it to relevant breastfeeding information.

Verbatim wording from the response
“Advice is available on the NHS.UK website on the safe use of slings – including information on the UK Sling Consortium’s ‘TICKS’ rules, and links to guidance from the Royal Society for the Prevention of Accidents and the Lullaby Trust on baby sling safety – in pages on caring for a newborn baby, and separately on safe sleep and preventing Sudden Infant Death Syndrome. However, on review, NHS England agree that this guidance could be easier to find and isn’t currently linked to breastfeeding information. Our Maternity Team will work with the NHS.UK website team so that guidance on the safe use of slings is easier to find, and is linked to more relevant website pages, such as on breastfeeding.”

Source location
Response from NHS England
Page 1 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Refer safe sling-use advice for consideration in NICE guidance.

Verbatim wording from the response
“Turning to antenatal advice given to women in healthcare settings, NHS Maternity Services are required to follow guidance from the National Institute for Health and Care Excellence (NICE), which develops evidence-based guidelines on what advice and care should be routinely provided. We are not aware of specific recommendations or advice on the safe use of slings, and we have referred this issue to NICE for consideration in response to your concerns. We have also passed on the details of this case to UNICEF-UK. As you may be aware, a significant proportion of maternity services in England work to achieve the standards of infant feeding advice and support”

Source location
Response from NHS England
Page 1 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Baby sling manufacturers are responsible for providing clear guidance on product suitability and safe use during breastfeeding.

Verbatim wording from the response
“Baby wearing or the use of baby slings may facilitate breastfeeding by helping mother and baby to stay close together. It is the responsibility of baby sling manufacturers to provide clear guidance on the use of their product, including suitability of the product to support breastfeeding and how this can be safely achieved.”

Source location
Response from DHSC
Page 1 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Department of Health and Social Care and NHS England are responsible for responding on baby-carrier and breastfeeding advice.

Verbatim wording from the response
“You also raise matters of concern regarding the availability and promotion of advice on the use of baby carriers and breastfeeding. I understand that the Department for Health and Social Care and NHS England will write to you separately on this issue.”

Source location
Response from OPSS
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Product manufacturers bear significant responsibility for providing parents with adequate guidance on the safe use of newborn carriers and slings.

Verbatim wording from the response
“There are a significant number of products marketed for use with newborns. In the context of limited time for midwives to provide advice in antenatal appointments, NHS England consider that the manufacturers of these products bear a significant responsibility for ensuring that parents receive adequate guidance on their safe use. I note that you have also written to the Office for Product Safety and Standards, and we are supportive of a revised industry standard in this area, in particular around the safe use of slings / carriers while breastfeeding.”

Source location
Response from NHS England
Page 2 · response
Published 28 December 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE is responsible for considering whether recommendations on safe sling use should be included in routine antenatal advice.

Verbatim wording from the response
“Turning to antenatal advice given to women in healthcare settings, NHS Maternity Services are required to follow guidance from the National Institute for Health and Care Excellence (NICE), which develops evidence-based guidelines on what advice and care should be routinely provided. We are not aware of specific recommendations or advice on the safe use of slings, and we have referred this issue to NICE for consideration in response to your concerns. We have also passed on the details of this case to UNICEF-UK. As you may be aware, a significant proportion of maternity services in England work to achieve the standards of infant feeding advice and support”

Source location
Response from NHS England
Page 1 · response
Published 28 December 2024
Open published response
21 Aug2018
Manchester West
Concerns raised1
1. Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Bolton NHS Foundation Trust
Stated actions 2
1. Bolton NHS Foundation Trust
  Request the Head of Midwifery, Divisional Nurse Director and Families Division Governance Lead to review safe-sleeping concerns.
2. Bolton NHS Foundation Trust
  Put relevant safe-sleeping documentation in place.
AI-generated summary

Louie Francis Bradley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Louie Francis Bradley died following breastfeeding in bed with his mother, who fell asleep. Concerns included advice to breastfeed in bed while side-by-side with the baby when the mother was fatigued, and incomplete documentation of key information and advice given to the patient.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone
Wider context from the report
“1. The midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued, this leads to inadvertent co-sleeping and as in this case can lead to death. ”
Source location
Louie Francis Bradley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Request the Head of Midwifery, Divisional Nurse Director and Families Division Governance Lead to review safe-sleeping concerns.

Verbatim wording from the response
“Following receipt of the Regulation 28 Report, I requested that the Head of Midwifery/Divisional Nurse Director and the Governance Lead for the Families Division review your concerns and would like to assure you that further actions in addition to the actions identified in the Serious Incident Report have been taken.”

Source location
2018-0261-Response-by-Bolton-NHS-Trust
Page 1 · response
Published 25 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Put relevant safe-sleeping documentation in place.

Verbatim wording from the response
“I have attached an Action Plan which details a number of improvements together with the relevant documentation which is now in place for your reference. I hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation.”

Source location
2018-0261-Response-by-Bolton-NHS-Trust
Page 1 · response
Published 25 September 2018
Open published response