Recurring concern

Inadequate safety controls for baby slings and carriers

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First reported 4 Apr 2014•Latest report 12 Dec 2024

Definition

What this concern includes

Includes safety-control failures specifically related to baby slings or carriers, including design or positioning guidance, warnings, breastfeeding-in-carrier advice, research or standards needed to identify and control positional-asphyxia and related risks.

Not included

  • Excludes general safe-sleeping concerns unrelated to use of a baby sling or carrier.
  • Excludes hoisting harnesses, patient slings and other clinical or lifting equipment unless the assertion specifically concerns baby slings or carriers.
  • Excludes generic infant-care, parenting or product-information deficiencies without a material baby-sling or carrier safety risk.
  • Excludes isolated injuries or deaths where no continuing deficiency in baby-sling or carrier safety controls is asserted.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
10

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

British Standards Institution1
Department of Health and Social Care1
NHS England1
Office for Product Safety and Standards1
University College London Hospitals NHS Foundation Trust1

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.

  1. West London

    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 individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of safety and positioning information for 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 action was interpreted

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

    PFD Monitor interpretation

    Convene a multidisciplinary roundtable to agree simple, consistent sling and carrier messaging, supported by accurate images and visual assets.

    Verbatim wording from the response

    “The Lullaby Trust is currently funding research into sling advice, and taking into account the timings of this project, we have agreed to convene a wider roundtable discussion to agree messaging for parents, families and stakeholders around the use of slings and carriers for young babies that is simpler and consistent. We are going to ensure we include a wide range of researchers and professionals who have contact with families, including breastfeeding experts and leading infant feeding organisations and babywearing professionals, to ensure one aligned message is agreed. We will ensure this includes images and other visual assets that give accurate depictions of using a sling or carrier.”

    Source location

    Response from The Lullaby Trust
    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

    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 British Standards Institution is responsible for changes to the voluntary baby-carrier safety standard.

    Verbatim wording from the response

    “Should there be any updates to Government or NHS advice regarding the safety of infants when in a baby sling or carrier, OPSS will bring this to the attention of relevant trade associations, including the Baby Products Industry Association. OPSS would also review the designation of the voluntary standard, to consider whether any amendments, accompanying notes or restrictions to the standard may be required. Changes to the standard itself would be a matter for the British Standards Institution, who I understand also received a copy of your Report.”

    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

    Businesses remain responsible for ensuring product safety instructions reflect the latest safety advice.

    Verbatim wording from the response

    “It will remain businesses’ responsibility to ensure that their product instructions for safe use take account of the latest safety advice.”

    Source location

    Response from OPSS
    Page 2 · response
    Published 28 December 2024

    Open published response
  2. Inner North London

    AI-generated summary

    Eric Laser Matthews · 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

    Eric Laser Matthews, born on 26 November 2013, was placed in a baby sling on 24 December 2013 and was later found not to be breathing. He suffered a significant hypoxic brain injury and died on 1 January 2014; the reported concern was that positional asphyxia associated with baby slings may be insufficiently known and publicised to parents.

    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 research and restricted knowledge of positional asphyxia risks from baby slings

    Wider context from the report

    “(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched. (2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely. ”

    Source location

    Eric Laser Matthews · 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 publicise baby sling positional asphyxia risks to parents

    Wider context from the report

    “(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched. (2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely. ”

    Source location

    Eric Laser Matthews · 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

    Investigated the feasibility of surveying infant deaths in unusual scenarios such as slings and car seats.

    Verbatim wording from the response

    “Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.”

    Source location

    2014-0151-Response-by-University-Hospital-London-NHS-Trust
    Page 1 · response
    Published 4 April 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

    Data protection, consent, rarity and locally held uncollated records prevent a useful survey or prospective study from being undertaken.

    Verbatim wording from the response

    “Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.”

    Source location

    2014-0151-Response-by-University-Hospital-London-NHS-Trust
    Page 1 · response
    Published 4 April 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

    Further progress would require coroners to liaise with sudden infant death clinicians and release available child death review data.

    Verbatim wording from the response

    “The way forward may be for the coroners to liaise with clinicians who are working on sudden infant death (ideally via FSIDS), and release whatever data is available from existing child death reviews.”

    Source location

    2014-0151-Response-by-University-Hospital-London-NHS-Trust
    Page 1 · response
    Published 4 April 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

    A study cannot be run from one centre, and undertaking one was outside the respondent’s professional interests and experience.

    Verbatim wording from the response

    “Since the ‘back to sleep’ campaign, a subset of SUDI have been considered very likely to have been asphyxial – more investigation revealed that these are often associated with additional risk factors (e.g. sharing a sofa with a parent). What a review of deaths in slings and car seats might do is identify possible additional risk factors, such as the age of the baby or the design of the sling. Being so rare, no useful conclusions could be reached from the experience of one centre, even a very large one.”

    Source location

    2014-0151-Response-by-University-Hospital-London-NHS-Trust
    Page 1 · response
    Published 4 April 2014

    Open published response
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Data last updated 7 September 2026