Violet Leona Jackman · Prevention of Future Deaths report

On 18th May 2020 I commenced an investigation into the death of Violet Leona Jackman. The investigation concluded on the 18th November 2020 and the conclusion was one of Narrative: Sudden and unexpected death of a baby where a Moses basket overturned whilst she was asleep in it.

The medical cause of death was
1a) Sudden unexpected death in a child with mild lower respiratory tract infection, associated with an accidental unsafe sleeping position

Violet Jackman was a baby who initially lived with both her parents and then after they separated, care was shared. Following her birth, the initial Health Visitor visit took place in accordance with usual practice. Safe sleeping advice was given to her mother who was present. On 17th May 2020, Violet Jackman was found unresponsive in a bed at her home address, ████████
████████. The Moses basket in which she had been sleeping had tipped over.

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.

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.

3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken, or if Health Visitor services were being reduced to support other front line services.