This learning briefing follows a Rapid Review in May 2026 in relation to the death of a 6 month old baby and where safer sleep, particularly co-sleeping with the baby, was a theme of the learning.
Our local Plymouth learning focused on key areas of strength and development so let’s take a look at these in more detail below.
Areas of strength…
Continuity of Care
The mother had continuity of care throughout her pregnancy and post birth and was seen by a consistent midwife and health visitor.
Smoking Cessation
The need to support the mother to stop smoking was identified and smoking cessation help was offered both pre and post birth. Smoking was identified as increasing the risk of sudden infant death syndrome (SIDS) and makes co-sleeping with babies very dangerous. The Lullaby Trust also advise co-sleeping is very dangerous if anyone has recently drunk alcohol, taken drugs or medication that makes you sleepy or if your baby was born prematurely (before 37 weeks of pregnancy) or weighed under 2.5kg or 5.5 pounds when they were born. The Lullaby Trust message is clear that you should never fall asleep on a sofa or armchair with your baby as it significantly increases their risk of SIDS. They are also at risk of accidental death as they can easily slip into a position where they are trapped and can’t breathe.
Professional Curiosity and Alcohol Use
Professional curiosity around alcohol use was good with all health services enquiring if parents used alcohol and illicit substances. Health services enquired whether either parent used alcohol or illicit substances as they were both involved in the care of the baby.
Domestic Abuse Routine Enquiry
Routine domestic abuse enquiry was asked by the health visitor and midwife when appropriate to do so.
Recognising Mother’s Low Mood
The mother was given an enhanced offer of support by the health visiting service when she was identified as having low mood. This included a referral to the GP, an offer of baby massage, timely appointments by her GP for her mental health and referral to and assessment by the perinatal mental health team.
Safer Sleep Information
Safer sleep information was consistently provided by professionals at regular intervals.
Areas for development…
Shared Access to Health Systems
This review highlighted that if midwifery services had access to System One, a computer clinical computer system, then information sharing would be strengthened and improve the quality of assessment and ongoing support for mothers, unborn babies and families
Seeing Babies Sleep Spaces
When undertaking home visits, midwives and health visitors should review the baby’s sleep environment to further promote safe sleeping practices. This approach should also involve other professionals where appropriate e.g. children’s services, family hubs, housing etc.
Assessing If Safer Sleep Advice is Being Followed
Following the death of her child the mother shared that she had been co-sleeping with her baby. Whilst safer sleep information was sensitively and routinely provided, including the risks of co-sleeping, assessing if that information was being followed was less a focus of the conversations with the family. Professionals shared the challenges they face in relying on self reporting by parents.
Identifying Family Vulnerabilities and Reviewing Support
There were times for the family that meant there was an increased risk of co-sleeping. This included anniversary of loss, increase alcohol use, decline in emotional health and the use of prescribed medication.
Learning into Practice: Ask Yourself….
DO I HAVE THE INFORMATION I NEED TO BEST SUPPORT THIS FAMILY?
This review highlighted how not all agencies have access to the same information. By considering if you feel you have all the information you need to help a family this can prompt you to either re-enter conversations with families or,where appropriate, contact other departments/agencies to discuss your work with a family.
DO I HAVE A FULL PICTURE OF WHERE THE BABY SLEEPS, DAY & NIGHT?
Understanding the lived experience of children is crucial to gather a full picture of what life looks like for them. When it comes to babies this includes how they are put to sleep, where they sleep and where they wake up, day and night. If we ask ourselves do we really understand what a babies sleep environment looks like then we give ourselves the best chance to understand and support families.
AM I SURE SAFER SLEEP ADVICE IS BEING FOLLOWED?
As mentioned above the mother of the baby in this review shared after her child’s death that she had been co-sleeping with her baby. Although lots of information on safe sleep and the risks of co-sleeping was shared, professionals were not aware the mother and baby were co-sleeping and as also highlighted earlier, our system relies on parents self reporting. Asking ourselves if we’re sure safer sleep advice is being followed encourages us to re-enter conversations with families in a non-judgemental way. If you are concerned a family is not practising safe sleep then you should speak to your safeguarding lead. The Lullaby Trust provide clear guidance on when co-sleeping is very dangerous for a baby and to never fall asleep with your baby on a sofa or armchair.
WHAT VULNERABILITIES DO THE PARENTS HAVE THAT I NEED TO CONSIDER IN RELATION TO SAFER SLEEP?
Certain life events or family circumstances can increase the vulnerability of parents/carers and may impact on their ability to follow safer sleep advice. For example the parents/carers in this review were managing a number of stressors i.e. grief due to family death, alcohol use, mental health. If we explore the wider family context but importantly then think about what this means for the family being able to follow safer sleep advice, our support and conversations can become more focused.
HAVE I PAID ATTENTION TO CHANGING CIRCUMSTANCES THAT MAY IMPACT ON SAFER SLEEP?
Following on from this we also know family circumstances can change. If we are alert to this, predicting possible stressful times etc, then we can guide our support and conversations with parents/carers to explore the implications of any changes/events. Is it likely to increase or decrease their ability to follow safer sleep advice?
HAVE I CHECKED THE FAMILY HAVE THE PRACTICAL RESOURCES THEY NEED & ARE USING THEM?
It’s important that families have access to the practical resources they need to follow safer sleep guidance and are supported to get them if not. It can be an expensive thing preparing for a baby and everything they need so having these conversations with families in a way that acknowledges this and helps them source equipment is crucial. Taking this point onto the next deeper level means us not just checking if they have the equipment they need but once they have it, are they using it? You might notice things still in boxes when you visit a family home and this could spur a conversation about if they need help unpacking it, putting it together or how has the baby been sleeping in the meantime?
What is the safer sleep message in Plymouth?
The Lullaby Trust
The Lullaby Trust has been referred to a number of times in the above content and that’s because in Plymouth we use The Lullaby Trust as our agreed and evidenced based safer sleep message. Their website has a range of resources available for multi agency professionals to understand what a safer sleep environment looks like for a baby and promotes the idea that safer sleep is everyone’s responsibility. To visit The Lullaby Trust please click HERE.
The Child Safeguarding Practice Review Panel: Learning Resources
When Safeguarding Children Partnerships do Rapid Reviews and Local Child Safeguarding Practice Reviews they report to the national Child Safeguarding Practice Review Panel. The Panel considers reports from across England and shares its learning via its website. Please take a look at the range of their excellent resources and they have a particular section on vulnerable babies, including safer sleep.
Click HERE for the main website page.
Click HERE for the vulnerable babies page.