Ocean-Leigh Hayes

Dear Mr Hughes Thank you for your letter received via email on the 20 November 2023, in which you have shared the Regulation 28 with associated actions for improvement following the inquest into the sad death ofOcean-Leigh Pauline Jean Hayes who sadly died in early infancy aged just 4 months in 2021. I note that whilst the conclusion was Sudden Unexplained Death in Infancy it is your view that some actions could be taken by the Health Board to minimise the risk of future deaths in similar circumstances. From your findings it became evident that the sleeping arrangements were not being physically reviewed by Health Visitors in all cases before a baby is 6 weeks old. The evidence you heard additionally raised concerns as to whether parents were being reminded of the risks of co-sleeping at all opportunities and the risks of bedding and pillows and so on. In order to review the pathways of education of the Health Visitors and communication with parents we have held several multidisciplinary meetings to consider the communication provided and to discuss where improvements could be made. Please find attached our assurance and improvement plan which has identified all opportunities for improvement and details the actions that have been and are being progressed to minimise the risk of any missed opportunities in the future. In summary, Cardiff and Vale UHB will monitor and implement the assurance plan to completion through the Children and Women Clinical Board assurance framework. 1

I hope that this information is helpful and offers the assurance you are seeking regarding the improvements instigated to ensure patients and their families in similar circumstances will be provided with the relevant information to consider the risks of co-sleeping and that Health Visitors will undertake the visual assessment of the baby's sleeping area before 6 weeks.