PFD report

Rifky GROSSBERGER · Prevention of Future Deaths report

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Issued 11 Mar 2020•Inner North 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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
2

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 accessible safety information for new parents about metal blind cord dangers
    Part of recurring concern: Inadequate warnings and awareness of blind-cord strangulation risks
  2. Unavailability of a national leaflet on metal blind cord dangers
    Part of recurring concern: Inadequate warnings and awareness of blind-cord strangulation risks
  3. Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers
    Part of recurring concern: Inadequate warnings and awareness of blind-cord strangulation risks
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.2

  1. Action

    Raise awareness of strangulation and suffocation risks among members through professional forums and social media platforms.

    Stated by Royal College of NursingStated completedThe respondent said that this action was complete when they made their response on 8 April 2020.
  2. Action

    Review and strengthen clinical webpage guidance on strangulation and suffocation risks for relevant nursing and health visiting professionals.

    Stated by Royal College of NursingStated completedThe respondent said that this action was complete when they made their response on 8 April 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The Healthy Child Programme and health visitors’ established safety advice are considered sufficient to address reminders about baby strangulation risks.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 accessible safety information for new parents about metal blind cord dangers

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate warnings and awareness of blind-cord strangulation 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

Unavailability of a national leaflet on metal blind cord dangers

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate warnings and awareness of blind-cord strangulation 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

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

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate warnings and awareness of blind-cord strangulation risks.

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

Raise awareness of strangulation and suffocation risks among members through professional forums and social media platforms.

Verbatim wording from the response

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

Source location

2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Page 2 · response
Published 8 April 2020

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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

Review and strengthen clinical webpage guidance on strangulation and suffocation risks for relevant nursing and health visiting professionals.

Verbatim wording from the response

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

Source location

2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Page 2 · response
Published 8 April 2020

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Healthy Child Programme and health visitors’ established safety advice are considered sufficient to address reminders about baby strangulation risks.

Verbatim wording from the response

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

Source location

2020-0070-Response-from-NHS-England-and-NHS-Improvement
Page 1 · response
Published 8 April 2020

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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

Existing NHS website advice on blind safety is considered sufficient to address accessible safety information for parents.

Verbatim wording from the response

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

Source location

2020-0070-Response-from-NHS-England-and-NHS-Improvement
Page 1 · response
Published 8 April 2020

Open published response

Other statements in published responses

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

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing Healthy Child Programme discussions and resources already address strangulation and suffocation risks for babies and children.

    Stated by Royal College of NursingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing Healthy Child Programme discussions and resources already address strangulation and suffocation risks for babies and children.

Verbatim wording from the response

“The Healthy Child Programme for the early life stages focuses on a universal preventative service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. The safety aspects of discussions with parents includes the potential risk of strangulation and suffocation, with Health Visitors highlighting and providing resources from the Child Accident Prevention Trusti and NHS online advice for new parentsii.”

Source location

2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Page 2 · response
Published 8 April 2020

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