Recurring concern

Inadequate warnings and awareness of blind-cord strangulation risks

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First reported 5 Jun 2014•Latest report 11 Mar 2020

Definition

What this concern includes

Includes failures of dedicated controls to warn about or raise awareness of blind-cord strangulation risks, including prompts for midwives, district nurses and other relevant professionals, public safety information, leaflets, campaigns and comparable warnings for parents, carers and other people exposed to the hazard.

Not included

Excludes generic child-safety, household-product or public-awareness deficiencies not specifically concerning blind-cord strangulation risks.
Excludes failures of blind-cord design, installation, physical safeguards or retrospective incident response where warning or awareness is not the deficient control.
Excludes warnings about other window coverings or unrelated household hazards unless the assertion explicitly concerns blind-cord strangulation.

Reports: 2
Individual concerns: 4
Date range: 2014–2020
Stated actions: 3

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 for Business, Innovation & Skills1

NHS England1

Royal College of Nursing1

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.

11 Mar2020
Inner North London
Concerns raised3
1. Lack of accessible safety information for new parents about metal blind cord dangers
2. Unavailability of a national leaflet on metal blind cord dangers
3. Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers
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
  Review and strengthen clinical webpage guidance on strangulation and suffocation risks for relevant nursing and health visiting professionals.
  Stated by Royal College of NursingStated completed
2. Action
  Raise awareness of strangulation and suffocation risks among members through professional forums and social media platforms.
  Stated by Royal College of NursingStated completed
Respondent positions 2
1. Position
  Existing NHS website advice on blind safety is considered sufficient to address accessible safety information for parents.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  The Healthy Child Programme and health visitors’ established safety advice are considered sufficient to address reminders about baby strangulation risks.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Rifky GROSSBERGER · 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

Rifky Grossberger became entangled in a metal blind cord in her cot on 31 July 2019 and died five days later after resuscitation. The principal concern was that her parents were unaware of the danger, and that safety information about blind cords may not be consistently provided to new parents by leaflets, healthcare professionals or other sources.

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 accessible safety information for new parents about metal blind cord dangers
Wider context from the report
“Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this. I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals. Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets. ████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger. I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future. The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet. ”
Source location
Rifky GROSSBERGER · 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
Unavailability of a national leaflet on metal blind cord dangers
Wider context from the report
“Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this. I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals. Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets. ████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger. I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future. The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet. ”
Source location
Rifky GROSSBERGER · 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
Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers
Wider context from the report
“Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this. I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals. Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets. ████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger. I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future. The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet. ”
Source location
Rifky GROSSBERGER · 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 and strengthen clinical webpage guidance on strangulation and suffocation risks for relevant nursing and health visiting professionals.

Verbatim wording from the response
“In considering your report, we have reviewed and strengthened our guidance about the potential risks of strangulation and suffocation on our clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. Further to this, we have also brought this matter to the attention of our members through Forums and their social media platforms.”

Source location
2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Page 2 · response
Published 8 April 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
Raise awareness of strangulation and suffocation risks among members through professional forums and social media platforms.

Verbatim wording from the response
“In considering your report, we have reviewed and strengthened our guidance about the potential risks of strangulation and suffocation on our clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. Further to this, we have also brought this matter to the attention of our members through Forums and their social media platforms.”

Source location
2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Page 2 · response
Published 8 April 2020
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
Existing NHS website advice on blind safety is considered sufficient to address accessible safety information for parents.

Verbatim wording from the response
“Following the inquest, you asked NHS England and Improvement (hereafter ‘NHSEI’) to address your concern regarding the need to find methods of delivering safety advice in an easily accessible format. This could be in the form of local and national leaflets to provide parents with the safety advice they need to look after their new born baby.”

Source location
2020-0070-Response-from-NHS-England-and-NHS-Improvement
Page 1 · response
Published 8 April 2020
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 Healthy Child Programme and health visitors’ established safety advice are considered sufficient to address reminders about baby strangulation risks.

Verbatim wording from the response
“You also asked NHSEI to address your concern around the need for healthcare professionals such as midwives and district nurses who look after new mums and their babies to be reminded of this particular danger.”

Source location
2020-0070-Response-from-NHS-England-and-NHS-Improvement
Page 1 · response
Published 8 April 2020
Open published response
5 Jun2014
Sunderland
Concerns raised1
1. Insufficient public awareness of blind-cord risks among infants, grandparents and carers
This report raised 1 other concern. 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 supporting partner-led blind-cord safety awareness campaigns through funding and collaboration.
  Stated by Department for Business, Innovation & SkillsStated in progress
Respondent positions 2
1. Position
  Established partner campaigns and networks are considered an effective response to increasing awareness of blind-cord safety risks.
  Stated by Department for Business, Innovation & SkillsExisting arrangements considered sufficient
1. Position
  Preventive delivery is led by the BBSA and RoSPA through partnerships and networks rather than undertaken solely by government.
  Stated by Department for Business, Innovation & SkillsRedirects responsibility
AI-generated summary

Sophie Allen · 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

Sophie Allen, aged 2 years, was found at home with a blind cord wrapped around her neck and was pronounced dead on 26 April 2014 after hospital transfer. The report highlighted the continuing risk of blind cords to young children, including risks from existing cords in homes and the need for wider public awareness.

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
Insufficient public awareness of blind-cord risks among infants, grandparents and carers
Wider context from the report
“Sophie's death was yet another example of the dangers that blind cords pose to the lives of young children. I understand that since 1999 there have been 28 such deaths in the UK due to looped cords (15 of them since 2010). I am aware that following reports from Coroners and other representations the new EN13120 released in February 2014 strengthened the child safety elements of the standard and that your Department continues to actively support safety campaigns which would include the distribution of leaflets and the provision of cleats and cord shorten. Sadly and despite these efforts public awareness and the need to act promptly to eliminate the risks associated with blind cords not only needs to continue but perhaps should be extended to cover a greater element of the population including infants, grandparents and carers. Although the new standard applies to new installations there will be millions of blind cords already fitted in homes occupied (or visited by children) that pose a very real risk of death as in Sophie's case. It may be that Sophie's family may also write to you. ”
Source location
Sophie Allen · 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 supporting partner-led blind-cord safety awareness campaigns through funding and collaboration.

Verbatim wording from the response
“BIS supports the BBSA’s “Make It Safe Campaign” which is run primarily with RoSPA through widespread distribution of the Make It Safe brochure, press releases, TV and radio programmes and interviews and use of social networking. Since 2011 the BBSA has produced and distributed 1.6 million Make It Safe leaflets (many through RoSPA). They have also produced a video, poster, vehicle and shop window stickers – more information can be found on their website http://www.makeitsafe.org.uk/ The leaflet has gone to every local authority in Wales and to the main children’s organisations (statutory and NGOs).”

Source location
2014-0256-Response
Page 1 · response
Published 5 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
Established partner campaigns and networks are considered an effective response to increasing awareness of blind-cord safety risks.

Verbatim wording from the response
“However, I believe there is an already established and effective network of partners who are well placed to take preventative action forward, led by the British Blind and Shutters Association (BBSA) and the Royal Society for the Prevention of Accidents (ROSPA). Below I outline some of the campaigns planned or already underway.”

Source location
2014-0256-Response
Page 1 · response
Published 5 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
Preventive delivery is led by the BBSA and RoSPA through partnerships and networks rather than undertaken solely by government.

Verbatim wording from the response
“However, I believe there is an already established and effective network of partners who are well placed to take preventative action forward, led by the British Blind and Shutters Association (BBSA) and the Royal Society for the Prevention of Accidents (ROSPA). Below I outline some of the campaigns planned or already underway.”

Source location
2014-0256-Response
Page 1 · response
Published 5 June 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Lack of accessible safety information for new parents about metal blind cord dangers

Unavailability of a national leaflet on metal blind cord dangers

Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Insufficient public awareness of blind-cord risks among infants, grandparents and carers

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.2

Actions described in response 2

Respondent positions 2

Actions described in response 1

Respondent positions 2