Safeguarding children at risk from sudden unexpected infant death

While the overall numbers of babies dying from SUDI are decreasing, a worrying number of deaths have been notified to the Panel as serious child safeguarding incidents. Between June 2018 and August 2019, the deaths of 40 babies from SUDI were reported to the Panel. Most of whom died after co-sleeping in bed or on a chair or sofa, often with parents who had consumed drugs or alcohol.

The review reveals families with babies at risk of dying in this way are often struggling with several issues, such as domestic violence, poor mental health or unsuitable housing. It found that these deaths often occur when families experience disruption to their normal routines and so are unable to engage effectively with safer sleeping advice.

Due to Covid-19 and the associated anxieties about money, social isolation and mental health issues, disruptions that led to the deaths of these infants may be more prominent at present.

To address this, the Panel is calling for local areas to reduce the risk of SUDI by incorporating it into wider strategies for responding to social and economic deprivation, domestic violence and parental mental health concerns. This should be backed up by new Government tools and processes to support frontline practitioners and local safeguarding partners to make these changes.

Leading SUDI expert and Child Safeguarding Practice Review Panel Member, Prof Peter Sidebotham said:

“It’s important that we give all families information about safe sleeping, but for some families who are struggling with multiple issues the existing information is simply not enough. This is not about blaming parents who have suffered such tragedies. This is a societal issue and we need to listen to and talk with families realistically and honestly so we can make sure that their babies sleep safely all the time.”

Findings and Recommendations

The review examines the deaths of 14 babies from 12 local areas to understand how professionals can best support parents to ensure that safer sleep advice is heard and embedded.

The findings show:

  • Families living within a context of recognised background risks, such as deprivation and overcrowding, domestic violence or poor mental health, are at heightened risk of losing a baby to SUDI. All those working with families need to recognise that and work together – this is not just an issue for midwives and health visitors.
  • We need a flexible and tailored approach to prevention that is responsive to the reality of people’s lives. That means talking honestly with parents about how they will cope in different situations to ensure every sleep is safe.
  • The best local arrangements for promoting safer sleeping involve a range of professionals as part of a relationship-based programme of support, embedded in wider initiatives to promote infant safety, health and well-being.
  • A prevent and protect practice model should be locally adopted to recognise the continuum of risk of SUDI, with support and interventions that are graded to reflect the needs of different families.

The review makes the following recommendations for the Department for Education, Department of Health and Social Care, Home Office and Public Health England:

  • To develop shared tools and processes to support front-line professionals from all agencies in working with families with children at risk to promote safer sleeping as part of wider initiatives around infant safety, health and well-being.
  • To work with the National Child Mortality Database to explore how data collected through child death reviews can be cross-checked against those collected through serious incident notifications.
  • To embed learning from this review as part of the refresh of the high impact areas in the Healthy Child Programme and the specification for health visiting.

The review also recommends that further practice-based research is undertaken to establish the efficacy of different interventions to reduce the risk of SUDI and into the use of behavioural insights and models of behaviour change.

The Panel is exploring options to commission this research and is interested in hearing from organisations to partner on this work.

The Panel’s annual report shows that babies are most at risk of serious harm and death from abuse and neglect. Therefore, it is undertaking a further in-depth review into the non-accidental injury of infants under one year old.


Initial briefing from ongoing research into the impact of coronavirus on child protection finds inconsistent guidance and resource inequalities, as well as professional values, driving practitioner behaviour on home visits and PPE

A combination of systemic factors have driven
children’s social workers to take risks during the
coronavirus pandemic, a study has found.

An initial briefing paper found nine overlapping
influences on social workers’ decisions, and in
particular on when and how they conducted visits.

These included professional values, government guidance and its interpretation, availability of IT provision for staff and for families, access to personal protective equipment (PPE) provision,
organisational openness to innovation and fears around imminent inspection.

All social workers who had contributed to the study – conducted across four local authorities – and had entered family homes described maintaining social distancing with young people as being

The paper called for staff to be given clearer and more consistent guidance that made clear they did not need to take personal risks they felt uncomfortable with.  It added that that leaders and managers – including within Ofsted – must address “organisational anxieties” by reiterating to frontline staff that the constraints Covid-19 has placed on practice will be taken into account in future monitoring and inspections.

The initial findings add depth to those of a recent national Community Care survey. Among our respondents, 63% of children’s social workers said they had carried out duties during the pandemic that caused them anxiety around infection risks. Only 37% of adults’ practitioners said likewise.

‘Significant differences’ based on technology

One key finding of the new study was that regardless of any guidance, social worker risk taking had been influenced by their equipment. Where provision of IT and, in particular, mobile technology was poor, many simply were not able to make the virtual visits that have become favoured for families deemed to have lower needs, making face-to-face visits more common.

“There were significant differences, from places where workers are given good smartphones, because WhatsApp is very popular with families,” said Harry Ferguson, a professor at the University of Birmingham who is leading the study.

“If it’s not possible to put that on your work phone, and families are not able to use Microsoft Teams, then virtual visits not on agenda – you see people by turning up, trying to do doorstep visits or seeing children in gardens where possible, but also going into homes.”

The availability of PPE also inevitably affected the level of risk practitioners have had to embrace. The study found that, several months into the pandemic, supply still varied from authority to authority, with variations in policy around when it could be used adding to the complexity of the picture.

Initial government guidance from April – which was widely criticised at the time – also suggested there was no need for children’s social workers to don PPE unless families were symptomatic. An update to the guidance in May continued to suggest this was the case but that social workers should take precautions including frequent hand-washing and social distancing, and using PPE if they felt a risk to themselves or others.

Further coverage of the report can be found –

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