PFD report

Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report

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Issued 15 Nov 2023•South Wales Central

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised2

  1. Failure to advise parents on risks associated with their baby's sleeping arrangements
    Part of recurring concern: Failure to ensure safe sleeping arrangements for infants and children
  2. Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age
    Part of recurring concern: Failure to ensure safe sleeping arrangements for infants and children
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.3

  1. Action

    Hold multidisciplinary meetings to review Health Visitor education and parent communication pathways and identify safety improvements.

    Stated by Cardiff and Vale UHBStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
  2. Action

    Ensure Health Visitors visually assess each baby's sleeping area before six weeks of age.

    Stated by Cardiff and Vale UHBStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
  3. Action

    Provide families with information about co-sleeping, bedding and pillow risks.

    Stated by Cardiff and Vale UHBStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.

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

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. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe sleeping arrangements for infants and children.

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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

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. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe sleeping arrangements for infants and children.

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

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
Page 1 · response
Published 22 November 2023

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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

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
Page 1 · response
Published 22 November 2023

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 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
Page 1 · response
Published 22 November 2023

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

    Implement the assurance and improvement plan to completion through the Children and Women Clinical Board assurance framework.

    Stated by Cardiff and Vale UHBStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.

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

Implement the assurance and improvement plan to completion through the Children and Women Clinical Board assurance framework.

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
Page 1 · response
Published 22 November 2023

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