Eric Laser Matthews · Prevention of Future Deaths report

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Issued 4 Apr 2014•Inner North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
1

Described in responses

Recipients and published responses

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. Insufficient research and restricted knowledge of positional asphyxia risks from baby slings
    Part of recurring concern: Inadequate safety controls for baby slings and carriers
  2. Failure to publicise baby sling positional asphyxia risks to parents
    Part of recurring concern: Inadequate safety controls for baby slings and carriers

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. University College London Hospitals NHS Foundation Trust

    Investigated the feasibility of surveying infant deaths in unusual scenarios such as slings and car seats.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. University College London Hospitals NHS Foundation Trust

    A study cannot be run from one centre, and undertaking one was outside the respondent’s professional interests and experience.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. University College London Hospitals NHS Foundation Trust

    Further progress would require coroners to liaise with sudden infant death clinicians and release available child death review data.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. University College London Hospitals NHS Foundation Trust

    Data protection, consent, rarity and locally held uncollated records prevent a useful survey or prospective study from being undertaken.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant 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

Insufficient research and restricted knowledge of positional asphyxia risks from baby slings

Wider context from the report

“(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched. (2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls for baby slings and carriers.

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

Failure to publicise baby sling positional asphyxia risks to parents

Wider context from the report

“(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched. (2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely. ”

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

Investigated the feasibility of surveying infant deaths in unusual scenarios such as slings and car seats.

Verbatim wording from the response

“Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.”

Source location

2014-0151-Response-by-University-Hospital-London-NHS-Trust
Page 1 · response
Published 4 April 2014

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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

A study cannot be run from one centre, and undertaking one was outside the respondent’s professional interests and experience.

Verbatim wording from the response

“Since the ‘back to sleep’ campaign, a subset of SUDI have been considered very likely to have been asphyxial – more investigation revealed that these are often associated with additional risk factors (e.g. sharing a sofa with a parent). What a review of deaths in slings and car seats might do is identify possible additional risk factors, such as the age of the baby or the design of the sling. Being so rare, no useful conclusions could be reached from the experience of one centre, even a very large one.”

Source location

2014-0151-Response-by-University-Hospital-London-NHS-Trust
Page 1 · response
Published 4 April 2014

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

Further progress would require coroners to liaise with sudden infant death clinicians and release available child death review data.

Verbatim wording from the response

“The way forward may be for the coroners to liaise with clinicians who are working on sudden infant death (ideally via FSIDS), and release whatever data is available from existing child death reviews.”

Source location

2014-0151-Response-by-University-Hospital-London-NHS-Trust
Page 1 · response
Published 4 April 2014

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

Data protection, consent, rarity and locally held uncollated records prevent a useful survey or prospective study from being undertaken.

Verbatim wording from the response

“Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.”

Source location

2014-0151-Response-by-University-Hospital-London-NHS-Trust
Page 1 · response
Published 4 April 2014

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