19 Dec 2016 Grace Joy Roseman · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Inadequate informed assessment and consideration of risks from bedside sleeper cribs View source Failure to keep crib and cradle safety standards up to date with bedside sleeper developments View source Failure to ensure modification of Bednest cribs in the marketplace View source Failure to ensure customers understand the mandatory need for crib modification View source Failure by industry to recognise the risk of infant head and neck entrapment at partially lowered sides View source Infant products with partially lowered sides posing entrapment risk View source Inadequate consultation with paediatric medicine and child development experts in child product safety standards View source Failure to fully accept the risk of infant death when using the crib with the half lowered side View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Display prominent website, blog and FAQ warnings that prohibit use of unmodified Bednest cribs and provide modification-kit ordering information.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Use social media, including Facebook, to publicise the safety warning and modification campaign.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017. View source
Action
Modify Bednest cribs to remove the half-down side functionality and modify the entire rental stock.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Monitor online second-hand sales sites and contact ambiguous-listing sellers about the required modification.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017. View source
Action
Send a regulatory safety notification about the half-folding side and modification kit to EU member states and publish the notice online.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Run repeat email campaigns warning consumers not to use unmodified Bednest cribs and urging modification-kit installation.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017. View source
Action
Disseminate modification-kit safety information through the Charity Retailers Association newsletter and website.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Contact Bednest and NCT customers repeatedly to warn about the hazard, promote modification and encourage information-sharing with subsequent owners.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Send modification kits to all known purchasers who had not previously requested one, using additional staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017. View source
Action
Work with the Institute of Health Visiting to inform health visitors about the modification and associated safety risk.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Offer customers collection, company modification and return of Bednest cribs instead of self-fitting the modification kit.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Continue identifying unmodified Bednest cribs and modifying them when they emerge for future reuse.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017. View source
Action
Publicise the modification kit and its availability through press, broadcast and online media coverage.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Develop, test and obtain approval for a self-fit modification kit, instructions, video demonstration and updated labels.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source See 11 more actions
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AI-generated summary
Grace Joy Roseman · 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
Grace Joy Roseman died on 9 April 2015 after being found with her head over the half-lowered side of an NCT Bednest crib. The medical cause of death was amended to pressure on the carotid sinus leading to positional asphyxia. The principal concern was that unmodified cribs remained in use or could be passed on or sold, including where customers were unaware that modification was needed or believed it was optional.
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. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate informed assessment and consideration of risks from bedside sleeper cribs
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to keep crib and cradle safety standards up to date with bedside sleeper developments
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure modification of Bednest cribs in the marketplace
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side.
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification . In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure customers understand the mandatory need for crib modification
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side.
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification. In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Failure by industry to recognise the risk of infant head and neck entrapment at partially lowered sides
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side .
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Infant products with partially lowered sides posing entrapment risk
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed , in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate consultation with paediatric medicine and child development experts in child product safety standards
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge .
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bednest Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to fully accept the risk of infant death when using the crib with the half lowered side
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side .
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification. In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Display prominent website, blog and FAQ warnings that prohibit use of unmodified Bednest cribs and provide modification-kit ordering information.
Verbatim wording from the response “21. In addition, prominent information is displayed on our website, including the home page, with easy click-ordering of modification kits. We have worked with Trading Standards, both before and since the inquest, to ensure that safety notices are in an appropriate form and have been appropriately updated in light of emerging information. We attach a screenshot showing the current homepage of the Bednest website (Attachment 3). As you will see, the safety warning is highly prominent, uses bold and red font and is the first thing anybody would see when visiting the website. The safety warning advises consumers that they must not use the Bednest Crib unless it is modified. It also advises of the risk of rapid injury or death of using the unmodified Bednest with the side in the half fold position.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Use social media, including Facebook, to publicise the safety warning and modification campaign.
Verbatim wording from the response “11. We have been working with our safety notification expert consultants to identify how best to harness publicity for the benefit of our corrective action campaign in order to maximize the prospects of individuals who might be in possession of an unmodified Bednest crib. In particular, our campaign has used social media sites, including Facebook, to publicise the warning and modification. Since 28th December this campaign rapidly reached over 225,000 people on Facebook and remains active on the Bednest Facebook page.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Modify Bednest cribs to remove the half-down side functionality and modify the entire rental stock.
Verbatim wording from the response “4. In light of evolving expert evidence and following consultation with the relevant regulatory authorities, we modified the Bednest Crib in November 2015 so as to remove the “half-down” functionality with the result that the side next to the parental bed can only be fully up or fully down. It is therefore no longer possible for any crib supplied after November 2015, to be left with the side half down. This modification was made on the basis of the “precautionary principle” in light of different opinions expressed by leading paediatricians as to the possibility of a baby being able to manoeuvre itself into the type of position in which Grace Roseman was reportedly found.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Monitor online second-hand sales sites and contact ambiguous-listing sellers about the required modification.
Verbatim wording from the response “22. We continue to work with Trading Standards in the daily monitoring of second hand reseller sites on the internet including Ebay, Gumtree and Schpock. Trading Standards have contacted these sites directly advising them not to sell unmodified Bednest cribs. Ebay have agreed not to list any unmodified Bednest cribs. At present Schpock have also advised that they have stopped the sale of any unmodified Bednest cribs and deleted all historic adverts which relate to unmodified Bednest cribs. We contact sellers where the listing is ambiguous to inform that the modification kit must be fitted. Despite assurances above we still keep a regular check on these websites in case some adverts are missed by their monitoring process.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Send a regulatory safety notification about the half-folding side and modification kit to EU member states and publish the notice online.
Verbatim wording from the response “8. A safety notification (being the appropriate form of regulatory response) was sent out 29th July 2016 alerting all EU member states of the risk posed by the half folding site and the modification kit. The RAPEX notice was published on the internet including on Trading Standards own sites.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Run repeat email campaigns warning consumers not to use unmodified Bednest cribs and urging modification-kit installation.
Verbatim wording from the response “12. On 21 December 2016 a further email campaign was launched, following consultation with RQA, Warwickshire and West Sussex Trading Standards, to the entire Bednest database, including all Bednest purchasers and those who had purchased any accessories. In this email we warned consumers as to the immediate risk of death if the Bednest was used with the side partially lowered and stated that the Bednest must not be used without the modification kit. The email was sent to people who already had the modification kit and urged them to fit the modification kit if they had not already done so. We have followed up with a campaign of repeat sending. We attach a copy of this email (Attachment 1).” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Disseminate modification-kit safety information through the Charity Retailers Association newsletter and website.
Verbatim wording from the response “23. We have also liaised with the Charity Retailers Association to inform them of the risk of the half fold side and the modification kit. They have included information as to the modification kit in their newsletter and put the information on their website.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Contact Bednest and NCT customers repeatedly to warn about the hazard, promote modification and encourage information-sharing with subsequent owners.
Verbatim wording from the response “7. In consultation with Trading Standards, product recall consultants and working with NCT we have endeavoured to directly contact all our customers and all NCT customers, to alert them to the hazard and motivate them to modify their Bednest, and to pass this information to anyone they had passed the Bednest to. This direct contact has consisted of a campaign of repeated emails, and letters for the small number for whom no email address was available. We included anybody on relevant databases who had purchased even just a replacement mattress or other accessory. NCT conducted a similar campaign to their known customers, as well as to 100,000 members, and passed details to us for follow up.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Send modification kits to all known purchasers who had not previously requested one, using additional staff.
Verbatim wording from the response “17. Our third phase of corrective action is to send a modification kit to all known purchasers who had not previously requested one. This is a joint action with NCT. We have hired extra staff to enable us to carry this out and we anticipate that we will have completed this third phase, by the end of March 2017. We attach a copy of the letter which accompanies the modification kit sent from Bednest (Attachment 2).” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Work with the Institute of Health Visiting to inform health visitors about the modification and associated safety risk.
Verbatim wording from the response “24. Our work with Trading Standards has led us to work with ████████ the head of the Institute of Health Visiting about the ways in which Health Visitors, who routinely go directly in to the homes of new parents to advise on safe sleep and where appropriate inform them about the modification and the safety risk associated with the half fold side. The Institute have 6000 health visitors as members but we understand that when they publicise on Facebook they reach up to around 9000 of the nearly 12000 population of health visitors. Further we have been advised that their posts can reach upwards of 50,000 or more interested parties. We attach a copy of their communication to members (Attachment 5).” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Offer customers collection, company modification and return of Bednest cribs instead of self-fitting the modification kit.
Verbatim wording from the response “13. In our communications, customers are offered the option of fitting the modification kit themselves or having the Bednest collected, modified by us and returned, if they do not wish to apply the modification kit themselves.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Continue identifying unmodified Bednest cribs and modifying them when they emerge for future reuse.
Verbatim wording from the response “Our corrective action efforts continue, including on-going monitoring and identification of second-hand users through our replacement mattress sales and the monitoring of on-line private sales. We currently maintain prominent information about the modification kit on our website.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Publicise the modification kit and its availability through press, broadcast and online media coverage.
Verbatim wording from the response “9. As you are aware, the fact of inquest was very widely reported, before, during and after the inquest. Prior to the inquest, ████████ were featured in a number of media outlets, including BBC programme Watchdog, to talk about the tragic death of Grace. We were contacted by these media organisations and alerted them to the modification and how this should be obtained. Watchdog has an average audience of 4-5million viewers. We also provided details of our modification kit and how this could be obtained for publishing on the Watchdog website. The story was also in The Sunday Times, The Mail on Sunday, The Mirror and The Telegraph amongst other regional news outlets as well as featuring on the BBC website and news App both as a report on the tragic incident and also as a dedicated ‘Bednest and safety: what you need to know’ article.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Develop, test and obtain approval for a self-fit modification kit, instructions, video demonstration and updated labels.
Verbatim wording from the response “6. In relation to cribs already in the market, we worked in collaboration with Trading Standards, NCT, product recall consultants and product designers, to design a simple self-fit modification kit that safely removes the half-fold capability, along with simple instructions and an online video demonstration that only requires 77 seconds to view. We also take the opportunity to include updated labels in the kit to bring the Bednest up to the latest specification. The kit, and its suitability for home fit by our purchasers, was tested and approved by the leading testing house, FIRA.” Source location 2016-0455-Response-by-Bednest
Open published response
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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 Product modifications, modification kits, ongoing monitoring and related corrective action are considered to fully address the reported safety issues.
Verbatim wording from the response “Bednest crib, we believe that we have taken the most appropriate and effective corrective action possible. We believe that the corrective action taken also addresses the various issues raised in your Regulation 28 Reports and has achieved the best practical results possible in the field.” Source location 2016-0455-Response-by-Bednest
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations