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NSPCC Learning from National Serious Case Reviews

Published: Tuesday, 19th September 2017

2016 - Baby D - death of a 12-week-old baby boy whilst co-sleeping with his mother.

Police arrested the parents, following anonymous allegations of heavy drinking and drug taking in the family home, but there was insufficient evidence and no further action was taken.

Background:No concerns were identified about the care of Baby D before or after his death. A range of agencies had been working with the family due to the increasingly challenging behaviour of Baby D’s half-sibling Child P. Mother had reported feeling overwhelmed by Child P’s behaviour and a social work assessment had taken place the day before Baby D’s death.

The key issues  identified include: need for some improvement in agencies’ delivery, recording and coordination of advice about safe sleeping and need for improved public and professional awareness of the issue of safe sleep.  Recommendations for the local safeguarding children board (LSCB) include:

  • Consider introducing consistent safe sleep assessment and recording arrangements for health professionals;
  • Carry out regular audits to evaluate the delivery and recording of safe sleeping advice.

See Safe Sleeping Guidance