26 Mar 2026 Madison James Bruce SMITH · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Promotion of prone sleeping by unqualified maternity and sleep providers View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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”.
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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
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15 Nov 2023 Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report South Wales Central
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Concerns raised 2
Failure to advise parents on risks associated with their baby's sleeping arrangements View source Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Cardiff and Vale UHB
Hold multidisciplinary meetings to review Health Visitor education and parent communication pathways and identify safety improvements.
View source
Cardiff and Vale UHB
Provide families with information about co-sleeping, bedding and pillow risks.
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Cardiff and Vale UHB
Ensure Health Visitors visually assess each baby's sleeping area before six weeks of age.
View source
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Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report
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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.
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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
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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
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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
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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
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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
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27 Jan 2023 Toby Wilbur Barwick · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
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1 Dec 2020 Violet Leona Jackman · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to elicit parents’ descriptions of sleeping arrangements View source Failure to ensure that shared-care parents understand safe sleeping guidance View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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14 Sep 2020 Isaac Jakob NEWTON · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Continuation of unsafe sleeping practices by parents View source
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department of Health and Social Care
Consider embedding learning from the review in the Healthy Child Programme’s transition-to-parenthood and early-weeks provision.
View source
Department of Health and Social Care
Work with stakeholders to develop shared tools and processes helping frontline professionals promote safer sleeping among families with children at risk.
View source
Department of Health and Social Care
Create and release short films promoting safe sleeping and co-sleeping advice during the pandemic and when babies will not sleep.
View source
Department of Health and Social Care
Publish refreshed Healthy Child Programme commissioning and delivery guidance incorporating safer-sleeping discussions at specified professional contacts.
View source
Department of Health and Social Care
Publish refreshed Healthy Child Programme High Impact Areas guidance highlighting hazards including cot bumpers, sleeping pods and SIDS risks.
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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.
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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
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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
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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
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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
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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
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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
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Concerns raised 1
Omission of advice not to co-sleep with premature or low birth weight babies from prominent co-sleeping guidance View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
Open source report
Concerns raised 1
Lack of timely safe-sleeping information for parents View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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21 Aug 2018 Louie Francis Bradley · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
Open published response
Concerns raised 1
Confusing and unrealistic guidance on bed-sharing when parents feel tired View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS Wales
Review the Welsh Government leaflet in light of the reported concerns about reducing sudden unexpected infant death risk.
View source
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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.
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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
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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
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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
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2 Jun 2014 Essa Shah · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
The Trust
Provide multilingual safe-sleep video content through the Trust website and DVDs.
View source
The Trust
Create Feeding Packs containing UNICEF co-sleeping leaflets in Bengali, Punjabi and Urdu.
View source
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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.
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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
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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
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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
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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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.