Recurring concern

Failure to ensure safe sleeping arrangements for infants and children

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First reported 2 Jun 2014•Latest report 26 Mar 2026

Definition

What this concern includes

Includes guidance, advice, communication, assessment, follow-up or care practices specifically dedicated to safe sleeping arrangements for infants and children.

Not included

Excludes general care, safeguarding or information-sharing deficiencies not specifically tied to safe sleeping arrangements.
Excludes factual descriptions of sleeping-related risk that do not identify an unsafe condition or deficient control.
Excludes unrelated equipment, housing or clinical-care failures unless they are specifically dedicated to safe sleeping arrangements.

Reports: 10
Individual concerns: 12
Date range: 2014–2026
Stated actions: 16

Reports 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.

Department of Health and Social Care4

Bedfordshire Hospitals NHS Foundation Trust1

Bolton NHS Foundation Trust1

Cardiff & Vale University LHB1

Luton and Dunstable University Hospital1

Portsmouth Hospitals University NHS Trust1

Staffordshire, Shropshire and Black Country Newborn and Maternity Network1

University College London Hospitals NHS Foundation Trust1

Welsh Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

26 Mar2026
Manchester South
Concerns raised1
1. Promotion of prone sleeping by unqualified maternity and sleep providers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Madison James Bruce SMITH · 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

Madison James Bruce Smith was found unresponsive in his cot on 18 October 2024 after being placed prone to sleep by a person describing themselves as a maternity nurse. He died in hospital, and the cause of death was unascertained, although prone sleeping was identified as increasing the risk of sudden unexpected death. The report raised concerns about the lack of statutory regulation, training and qualification requirements for maternity nurses and agencies, and the misleading use of the term “nurse”.

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
Promotion of prone sleeping by unqualified maternity and sleep providers
Wider context from the report
“3.The inquest was told that the promotion of prone sleeping by unqualified individuals describing themselves as maternity nurses and experts in sleep poses a very significant risk to a young baby. A baby will sleep more deeply in a prone position which is why superficially it can seem to be a solution where a baby sleeps poorly. However, whenever a young baby is placed in such a position it will increase the risk that they will die suddenly and unexpectedly. All health professionals need to be vigilant in continuing to emphasise the national guidance on safe sleeping and be vigilant in flagging up to a family that prone sleeping in a child that cannot independently turn over is not a solution to a poor sleep routine but rather is a factor that increases the risk of a sudden and unexpected death. ”
Source location
Madison James Bruce SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Nov2023
South Wales Central
Concerns raised2
1. Failure to advise parents on risks associated with their baby's sleeping arrangements
2. Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Hold multidisciplinary meetings to review Health Visitor education and parent communication pathways and identify safety improvements.
  Stated by Cardiff and Vale UHBStated completed
2. Action
  Provide families with information about co-sleeping, bedding and pillow risks.
  Stated by Cardiff and Vale UHBStated planned
3. Action
  Ensure Health Visitors visually assess each baby's sleeping area before six weeks of age.
  Stated by Cardiff and Vale UHBStated planned
AI-generated summary

Ocean-Leigh Pauline Jean Hayes · 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

Ocean-Leigh Pauline Jean Hayes was aged 4 months when she died at home on 22 December 2021 after co-sleeping with her mother. Concerns included health visitors not always physically reviewing infant sleeping arrangements and potential missed opportunities to risk assess bedding, positioning and other co-sleeping arrangements, and to advise parents about risks.

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
Failure to advise parents on risks associated with their baby's sleeping arrangements
Wider context from the report
“(1) Guidance requires health visitors to physically review sleeping arrangements before the baby is 6 weeks old. (2) I heard evidence that this was not always being done. (3) There may be missed opportunities to physically risk assess sleeping arrangements including inter alia bedding, blankets, pillows, mattress and positioning, particularly where co-sleeping is a factor, and missed opportunities to advise parents on risks they may be taking. ”
Source location
Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age
Wider context from the report
“(1) Guidance requires health visitors to physically review sleeping arrangements before the baby is 6 weeks old. (2) I heard evidence that this was not always being done. (3) There may be missed opportunities to physically risk assess sleeping arrangements including inter alia bedding, blankets, pillows, mattress and positioning, particularly where co-sleeping is a factor, and missed opportunities to advise parents on risks they may be taking. ”
Source location
Ocean-Leigh Pauline Jean Hayes · 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
Hold multidisciplinary meetings to review Health Visitor education and parent communication pathways and identify safety improvements.

Verbatim wording from the response
“In order to review the pathways of education of the Health Visitors and communication with parents we have held several multidisciplinary meetings to consider the communication provided and to discuss where improvements could be made. Please find attached our assurance and improvement plan which has identified all opportunities for improvement and details the actions that have been and are being progressed to minimise the risk of any missed opportunities in the future.”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 22 November 2023
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 families with information about co-sleeping, bedding and pillow risks.

Verbatim wording from the response
“From your findings it became evident that the sleeping arrangements were not being physically reviewed by Health Visitors in all cases before a baby is 6 weeks old. The evidence you heard additionally raised concerns as to whether parents were being reminded of the risks of co-sleeping at all opportunities and the risks of bedding and pillows and so on.”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 22 November 2023
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
Ensure Health Visitors visually assess each baby's sleeping area before six weeks of age.

Verbatim wording from the response
“From your findings it became evident that the sleeping arrangements were not being physically reviewed by Health Visitors in all cases before a baby is 6 weeks old. The evidence you heard additionally raised concerns as to whether parents were being reminded of the risks of co-sleeping at all opportunities and the risks of bedding and pillows and so on.”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 22 November 2023
Open published response
27 Jan2023
East London
Concerns raised1
1. Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Toby Wilbur Barwick · 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

Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.

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
Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
Wider context from the report
“1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome (“SIDS”). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied. ”
Source location
Toby Wilbur Barwick · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Dec2020
Manchester South
Concerns raised2
1. Failure to elicit parents’ descriptions of sleeping arrangements
2. Failure to ensure that shared-care parents understand safe sleeping guidance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue providing health visitors and their teams with evidence and advice to support both parents’ engagement in infant care.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Violet Leona Jackman · 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

Violet Leona Jackman was a baby who was found unresponsive on 17 May 2020 in a bed at her home; the Moses basket in which she had been sleeping had tipped over. Concerns included safe-sleeping advice being given only to her mother despite shared care, a lack of detailed checking of sleeping arrangements, and reduced Health Visitor availability during the first wave of Covid-19.

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
Failure to elicit parents’ descriptions of sleeping arrangements
Wider context from the report
“2. The guidance was given as a series of points. The inquest heard that as a general rule, health visitors do not ask parents to explain in a free text style the sleeping arrangements. It is likely if they had asked for such a description, then they would have been made aware of how the guidance had been interpreted and the sleeping arrangement in place. If they had then the inquest was told that her parents would have been told that the location of the basket was inconsistent with safe sleeping. ”
Source location
Violet Leona Jackman · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure that shared-care parents understand safe sleeping guidance
Wider context from the report
“1. Safe sleeping advice was given to her mother, although it was clear that care would be shared. There was no clear way of ensuring that both parents understood the guidance given or following up that the advice had been shared in detail. ”
Source location
Violet Leona Jackman · 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
Continue providing health visitors and their teams with evidence and advice to support both parents’ engagement in infant care.

Verbatim wording from the response
“Fathers have an equally vital role during pregnancy and throughout their child’s life and the first few weeks and months are critical. We will continue to provide health visitors and their teams with evidence and advice on how to ensure both fathers and mothers are supported to adapt to parenthood and engaged in the care of their child.”

Source location
2020-0263-Response-from-Department-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 4 January 2021
Open published response
14 Sep2020
Blackpool and the Fylde
Concerns raised1
1. Continuation of unsafe sleeping practices by parents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Consider embedding learning from the review in the Healthy Child Programme’s transition-to-parenthood and early-weeks provision.
  Stated by Department of Health and Social CareStated planned
2. Action
  Work with stakeholders to develop shared tools and processes helping frontline professionals promote safer sleeping among families with children at risk.
  Stated by Department of Health and Social CareStated planned
3. Action
  Create and release short films promoting safe sleeping and co-sleeping advice during the pandemic and when babies will not sleep.
  Stated by Department of Health and Social CareStated completed
1. Action
  Publish refreshed Healthy Child Programme commissioning and delivery guidance incorporating safer-sleeping discussions at specified professional contacts.
  Stated by Department of Health and Social CareStated planned
2. Action
  Publish refreshed Healthy Child Programme High Impact Areas guidance highlighting hazards including cot bumpers, sleeping pods and SIDS risks.
  Stated by Department of Health and Social CareStated planned
AI-generated summary

Isaac Jakob NEWTON · 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

Isaac Newton was a previously healthy four-month-old baby who died after being placed in a double bed and sleeping alongside his father and half-sibling. He was found unresponsive the following morning, and the inquest recorded that his airway was obstructed by the weight of an adult body overlying him, depriving him of oxygen. The principal concern was the risk to young infants from unsafe sleeping practices, including co-sleeping with adults or older children and potential impairment from drug or alcohol use.

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
Continuation of unsafe sleeping practices by parents
Wider context from the report
“(1)My concern relates to the risk posed to young infants by unsafe sleeping practices. This inquest involved a young child who was sleeping in a bed with a Parent and a Half – sibling. This was the fourth inquest I have concluded in 2020 that has involved a child that has died whilst sleeping in or on the parental bed. All of these inquests have involved relatively young parents. In three of the four inquests alcohol or drug use was a factor. Although guidance is provided to new parents about the dangers posed by an unsafe sleeping environment, I am concerned that the message is not being appreciated and / or followed. The evidence received from Isaac’s Parents was illustrative. His Mother informed the court that she had received advice from health visitors about the potential risks of a child co-sleeping with an adult but had clearly chosen not to follow the advice despite having a suitable cot available for him to sleep in. Isaac’s Father by contrast told the court that he could not recall receiving such advice. He gave the impression that he was unaware that the child may be at risk were he to use cannabis before co-sleeping, and in preferring to co – sleep rather than place Isaac in the cot he was following the practice he knew Isaac’s Mother adopted when Isaac was residing with her. Isaac’s Mother gave the impression that Isaac was not in jeopardy when he slept with her and his Half – sibling during the night because there was no risk that she would unknowingly roll over during the night. I am concerned that despite efforts to provide guidance to parents about what may amount to an unsafe sleeping environment some parents are continuing to place often very young children at risk. I concluded that it would be remiss of me as Senior Coroner for this coronial area were I not to raise this concern in light of the number of inquests we have concluded during which an unsafe sleeping environment has been adjudged to have played a role in the child’s death. I am aware that the Department of Health & Social Care did in July of this year publish details of a major review into improving health outcomes for babies and young children and so I have chosen to forward this letter to the Parliamentary Under Secretary with responsibility for that review as the concern I raise may be of relevance. ”
Source location
Isaac Jakob NEWTON · 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
Consider embedding learning from the review in the Healthy Child Programme’s transition-to-parenthood and early-weeks provision.

Verbatim wording from the response
“The report, which you have referenced, highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:”

Source location
2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Page 2 · response
Published 16 November 2020
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 stakeholders to develop shared tools and processes helping frontline professionals promote safer sleeping among families with children at risk.

Verbatim wording from the response
“The report, which you have referenced, highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:”

Source location
2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Page 2 · response
Published 16 November 2020
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
Create and release short films promoting safe sleeping and co-sleeping advice during the pandemic and when babies will not sleep.

Verbatim wording from the response
“To promote safe sleeping messages regarding babies and co-sleeping, Public Health England, working with the Lullaby Trust, have created two short films that have been released this year. The films give advice on caring for babies during the Covid-19 pandemic⁵, and when your baby won’t sleep⁶.”

Source location
2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 16 November 2020
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
Publish refreshed Healthy Child Programme commissioning and delivery guidance incorporating safer-sleeping discussions at specified professional contacts.

Verbatim wording from the response
“Public Health England advise that in Quarter 3, 2020/21, it plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, that includes safer sleeping discussions at specific interactions between health visitors and school nurses with parents and carers. In addition, Public Health England plans to publish refreshed High Impact Areas for the Healthy Child Programme in Q3, 2020/21 which will highlight the potential for harm from new hazards such as cot bumpers and sleeping pods and the dangers associated with SIDS.”

Source location
2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 16 November 2020
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
Publish refreshed Healthy Child Programme High Impact Areas guidance highlighting hazards including cot bumpers, sleeping pods and SIDS risks.

Verbatim wording from the response
“Public Health England advise that in Quarter 3, 2020/21, it plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, that includes safer sleeping discussions at specific interactions between health visitors and school nurses with parents and carers. In addition, Public Health England plans to publish refreshed High Impact Areas for the Healthy Child Programme in Q3, 2020/21 which will highlight the potential for harm from new hazards such as cot bumpers and sleeping pods and the dangers associated with SIDS.”

Source location
2020-0174-Response-from-Dept-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 16 November 2020
Open published response
14 Feb2020
Leicester City and South Leicestershire
Concerns raised1
1. Omission of advice not to co-sleep with premature or low birth weight babies from prominent co-sleeping guidance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marley Hope Slack · 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

Marley Hope Slack was born prematurely as the smaller of twins and died on 20 February 2019 after being found unresponsive in her parents’ bed. The report raised concern that the Trust’s prominent co-sleeping advice did not state that premature or low-birth-weight babies should not be co-slept with, and the inquest heard that her sleeping environment presented more than a minimal risk of sudden infant death.

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
Omission of advice not to co-sleep with premature or low birth weight babies from prominent co-sleeping guidance
Wider context from the report
“The Red Book for your Trust contains in its inside cover a colourful list of 'Do's' and 'Don'ts' regarding co-sleeping which is obviously meant to be eye catching and for quick reference. You have accredited the information to the Lullaby Trust. I am concerned as the 'Don't section on co-sleeping does not include that premature or low birth weight babies should not be co-slept with whereas the rest of the Lullaby Trust's advice about not co-sleeping if you smoke, drink or take drugs is quoted. I acknowledge that the advice is repeated in full in 'The Safe Sleep Assessment' section inside the booklet at page 15. However, if you are providing information that appears to be designed for immediate impact it should contain the appropriate correct information and advice. ”
Source location
Marley Hope Slack · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Jul2019
Portsmouth and South East Hampshire
Concerns raised1
1. Lack of timely safe-sleeping information for parents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Require midwives to document and confirm safe-sleeping advice on the post-birth discharge checklist.
  Stated by Portsmouth Hospitals University NHS TrustStated completed
2. Action
  Provide women with separate safe-sleeping information from the Child Health Record at discharge after birth.
  Stated by Portsmouth Hospitals University NHS TrustStated completed
AI-generated summary

Ezra James BOULTON · 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

Ezra James Boulton, aged two months, died on 20 May 2018 after being found unresponsive while co-sleeping with his mother on a sofa; alcohol had been consumed and he could not be resuscitated. The principal concerns were inadequate continuity of antenatal care, insufficient early safe-sleeping information for parents, and midwives’ lack of awareness about the legal implications of infant deaths involving co-sleeping and alcohol or drugs.

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 timely safe-sleeping information for parents
Wider context from the report
“(3) At Ezra's inquest I was told that as baby had been delivered safely with no significant injuries to mum (i.e. no significant tearing or blood loss) that the family were encouraged to leave fairly rapidly. On discharge, the focus of information sharing and care was distinctly focused on after-care for the mother. The family did not recall being given any information directly on safe-sleeping; either at antenatal appointments or at a post-natal stage from any midwife or Health Visitor. Any information they were given was provided almost as an after-thought and given in the form of a leaflet which it was suggested that they read. I was told that the first HV appointment the family received was approximately seven weeks after Ezra had been born. I believe that making safe sleeping information readily available to all parents at an early stage may significantly reduce the risk of future infant deaths due to co-sleeping. ”
Source location
Ezra James BOULTON · 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
Require midwives to document and confirm safe-sleeping advice on the post-birth discharge checklist.

Verbatim wording from the response
“PHT has a discharge checklist sticker which is placed in the woman’s medical records following birth and includes “safe sleeping” and must be ticked by the midwife on discharge to confirm that the woman has been advised about safe sleeping. There is also a safe sleeping leaflet which is usually given to women on discharge as part of a package of advice leaflets. However, the Hampshire Safeguarding Children’s Board is currently reviewing the Safe Sleeping Leaflet with a view to producing a more engaging version that raises the profile of this important issue.”

Source location
2019-0222-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 2 · response
Published 13 September 2019
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 women with separate safe-sleeping information from the Child Health Record at discharge after birth.

Verbatim wording from the response
“In the meantime, on discharge after birth, PHT midwives are giving women a separate photocopy of page 9 of the Child Health Record (red book) which contains advice about safe sleeping as well as details of the Lullaby Trust and NHS Choices where further advice can be obtained. This handheld book is normally given to women by their health visitor and not PHT midwives.”

Source location
2019-0222-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 3 · response
Published 13 September 2019
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Request the Head of Midwifery, Divisional Nurse Director and Families Division Governance Lead to review safe-sleeping concerns.
  Stated by Bolton NHS Foundation TrustStated completed
2. Action
  Put relevant safe-sleeping documentation in place.
  Stated by Bolton NHS Foundation TrustStated completed
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
23 Apr2015
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Confusing and unrealistic guidance on bed-sharing when parents feel tired
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the Welsh Government leaflet in light of the reported concerns about reducing sudden unexpected infant death risk.
  Stated by NHS WalesStated completed
Respondent positions 1
1. Position
  The Welsh Government leaflet should continue unchanged because it reflects current evidence, aligns with NICE guidance, and the review recommended no amendments.
  Stated by NHS WalesExisting arrangements considered sufficient
AI-generated summary

Efan Robert James · 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

Efan Robert James was found unresponsive after being placed in a bed shared by his mother and a friend, and died after being taken to hospital. The report raised concern that government advice about bed-sharing was confusing because assessing whether parents feel “very tired” was considered unrealistic.

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
Confusing and unrealistic guidance on bed-sharing when parents feel tired
Wider context from the report
“That the advice given by Welsh Assembly Government in the publication “Reduce the risk of cot death” is confusing. It suggests that parents should not share a bed with their baby if they “feel very tired”. Parents of young children will frequently feel tired and gauging whether they are “very tired” is an unrealistic test. ”
Source location
Efan Robert James · 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
Review the Welsh Government leaflet in light of the reported concerns about reducing sudden unexpected infant death risk.

Verbatim wording from the response
“Following your Regulation 28 letter I asked the Wales Child Death Review team to review the Welsh Government leaflet in light of your comments. They have concluded that the leaflet should continue to be used, and they did not recommend any changes to it. They have reiterated the importance of disseminating the advice mentioned above about how to reduce the risk of sudden unexpected infant death through safe sleeping practices and maintaining a smoke free environment. This message continues to be disseminated by primary care health professionals across Wales. Welsh Government is continuing to explore effective ways of supporting parents to protect their babies from sudden unexpected infant death.”

Source location
2015-0158-Response-by-Welsh-Government
Page 2 · response
Published 23 April 2015
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 Welsh Government leaflet should continue unchanged because it reflects current evidence, aligns with NICE guidance, and the review recommended no amendments.

Verbatim wording from the response
“The Wales Child Death Review published a report on sudden unexpected infant death in January 2015 (available at http://www.wales.nhs.uk/sitesplus/888/opendoc/256680). The report emphasised that these sad events of infant death are a complex problem with many possible factors. The review concluded that the advice leaflet provided by Welsh Government was based on the best possible current evidence about minimising risk in the baby’s environment, and reducing factors contributing to risk. The report emphasised that even when all the advice is adhered to, sadly there are still some unexplained infant deaths.”

Source location
2015-0158-Response-by-Welsh-Government
Page 1 · response
Published 23 April 2015
Open published response
2 Jun2014
Bedfordshire and Luton
Concerns raised1
1. Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide multilingual safe-sleep video content through the Trust website and DVDs.
  Stated by The TrustStated completed
2. Action
  Create Feeding Packs containing UNICEF co-sleeping leaflets in Bengali, Punjabi and Urdu.
  Stated by The TrustStated planned
Respondent positions 1
1. Position
  Translation of the Department of Health leaflet cannot be facilitated because of considerable practical and financial implications, and the Department no longer produces it.
  Stated by The TrustUnable to act
AI-generated summary

Essa Shah · 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

Essa Shah, aged eight weeks, went to sleep in the same bed as his mother following a feed and was later found unresponsive. The report raised concern that hospital literature about the dangers of co-sleeping was available only in English.

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
Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English
Wider context from the report
“1. That the literature, setting out the dangers of co-sleeping which the hospital hand to new mothers being discharged, is only available in the English Language. ”
Source location
Essa Shah · 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
Provide multilingual safe-sleep video content through the Trust website and DVDs.

Verbatim wording from the response
“In addition to leaflets, the Trust has produced a video, in three languages (English, Polish and Urdu) which is available on the Trust’s website and on DVD. The video includes a section about discharge and caring for your baby at home. The video was produced in response to a consultation with local communities who told us that whilst it was common for women to speak their mother tongue, they were often unable to read it.”

Source location
2014-0250-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 2 June 2014
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
Create Feeding Packs containing UNICEF co-sleeping leaflets in Bengali, Punjabi and Urdu.

Verbatim wording from the response
“DoH no longer produces this leaflet, we are not able to approach them for their assistance. However, UNICEF produce a leaflet called “Sharing a bed with your baby” which is available in 11 languages, three of which are relevant to the population we serve. The Trust will now ensure Feeding Packs are created containing this leaflet in Bengali, Punjabi and Urdu; the leaflet is not available in Polish so we will continue to use the video we have produced and verbal communication.”

Source location
2014-0250-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 2 June 2014
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
Translation of the Department of Health leaflet cannot be facilitated because of considerable practical and financial implications, and the Department no longer produces it.

Verbatim wording from the response
“The Community Midwives have prompt sheets to ensure that safe sleeping practices are discussed with women face to face and they will shortly be equipped with iPads to facilitate communication with anyone who is uncertain as to what they are being told verbally. The Trust is unable to facilitate the translation of the Department of Health leaflet, which is only available in English, due to the considerable practical and financial implications. As the”

Source location
2014-0250-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 2 June 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Promotion of prone sleeping by unqualified maternity and sleep providers

Concerns raised2

Failure to advise parents on risks associated with their baby's sleeping arrangements

Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices

Concerns raised2

Failure to elicit parents’ descriptions of sleeping arrangements

Failure to ensure that shared-care parents understand safe sleeping guidance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Continuation of unsafe sleeping practices by parents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Omission of advice not to co-sleep with premature or low birth weight babies from prominent co-sleeping guidance

Concerns raised1

Lack of timely safe-sleeping information for parents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Confusing and unrealistic guidance on bed-sharing when parents feel tired

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Actions described in response 1

Actions described in response 5

Actions described in response 2

Actions described in response 2

Actions described in response 1

Respondent positions 1