PFD report

James Robert Michael ALDERMAN · Prevention of Future Deaths report

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Issued 12 Dec 2024•West London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
7

Of 4 recipients

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of guidance on breastfeeding young babies in carriers/slings
    Part of recurring concern: Inadequate safety controls for baby slings and carriersPart of recurring concern: Unsafe breastfeeding arrangements exposing babies to suffocation risks
  2. Risk of suffocation for young babies in carriers/slings
  3. Lack of safety and positioning information for young babies in carriers/slings
    Part of recurring concern: Inadequate safety controls for baby slings and carriers
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Work with NHS England to establish consistent guidance on sling use and breastfeeding.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 December 2024.
  2. Action

    Engage key stakeholders, including UNICEF UK, to develop appropriate messaging about baby carriers and breastfeeding.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2024.
  3. Action

    Consider ways to supplement Better Health – Start for Life content about baby carriers and breastfeeding.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Baby sling manufacturers are responsible for providing clear guidance on product suitability and safe use during breastfeeding.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for baby slings and carriers; Unsafe breastfeeding arrangements exposing babies to suffocation risks.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Risk of suffocation 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for baby slings and carriers.

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

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

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

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

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

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

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 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

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

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 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

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

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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learnings across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 December 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Most concerns in the report fall outside the department’s scope, so it will not directly undertake responsive work on them.

    Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.
  2. 2

    NHS England and the Office for Product Safety and Standards will respond separately to concerns allocated to them.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    Merton Council Trading Standards is leading the investigation and communications with the supplying business.

    Stated by Office for Product Safety and StandardsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learnings across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jimmy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

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

Most concerns in the report fall outside the department’s scope, so it will not directly undertake responsive work on them.

Verbatim wording from the response

“Your report sets out several ‘matters of concern’ following your investigation. While the majority of these are outside the scope of my department, my officials have been working closely with colleagues in NHS England and the Office for Product Safety and Standards (OPSS) within the Department for Business and Trade to ensure all of the concerns are being adequately addressed. Each organisation will respond to you separately.”

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

NHS England and the Office for Product Safety and Standards will respond separately to concerns allocated to them.

Verbatim wording from the response

“Your report sets out several ‘matters of concern’ following your investigation. While the majority of these are outside the scope of my department, my officials have been working closely with colleagues in NHS England and the Office for Product Safety and Standards (OPSS) within the Department for Business and Trade to ensure all of the concerns are being adequately addressed. Each organisation will respond to you separately.”

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

Merton Council Trading Standards is leading the investigation and communications with the supplying business.

Verbatim wording from the response

“Merton Council Trading Standards are leading the investigation into the circumstances of this case, and on communication with the business that supplied the product, as they are based in the London Borough of Merton. We understand that the manufacturer of the product is based outside the UK. Initial intelligence gathering by OPSS has indicated that the product cites compliance with an earlier version of the standard for these types of products, which is not designated by Government. These matters will be the subject of investigation as to whether the product was compliant with the relevant regulations at the time of supply.”

Source location

Response from OPSS
Page 2 · response
Published 28 December 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026