Source · Prevention of Future Deaths

Marley Slack

Ref: 2020-0040 Date: 14 Feb 2020 Coroner: Dianne Hocking Area: Leicester City and South Leicestershire Responses identified: 1 / 1 View PDF

The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.

Date 14 Feb 2020

56-day deadline 10 Apr 2020

Responses identified 1 of 1

Child Death (from 2015) Other related deaths

Coroner's concerns

AI summary

The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: The Red Book for your Trust contains in its inside cover a colourful list of `Do's' and' Don'ts' regarding co-sleeping which is obviously meant to be eye catching and for quick reference. You have accredited the information to the Lullaby Trust. I am concerned as the `Don't section on co-sleeping does not include that premature or low birth weight babies should not be co-slept with whereas the rest of the Lullaby Trust's advice about not co-sleeping if you smoke, drink or take drugs is quoted. I acknowledge that the advice is repeated in full in `The Safe Sleep Assessment section inside the booklet at page 15. However, if you are providing information that appears to be designed for immediate impact it should contain the appropriate correct information and advice.

Responses

1 respondent

the Newborn and Maternity Network

PDF

Noted

The document provides general guidance on safer sleep practices for newborns, focusing on recommendations for reducing the risk of sudden infant death syndrome (SIDS). (AI summary)

View full response

Always place your baby on their back to sleep Place your baby to sleep in a separate cot or Moses basket in the same room as you for the first 6 months Breastfeed your baby if you can Keep your baby smoke free during pregnancy and after birth Don’t cover your baby’s face or head Don't sleep in the same bed as your baby if you smoke, drink, take drugs or your baby was premature or low birth weight Never sleep on a sofa or armchair with your baby Do... Don’t... With kind permission of The Lullaby Trust (see page 15 for further information) Safer sleep

Report sections

Investigation and inquest

On Twenty-Sixth February 2019 I commenced an investigation into the death of Marley Hope Slack aged 2 Months. The investigation concluded at the end of the inquest on Twenty-Eighth January 2020. The conclusion of the inquest was: Narrative Conclusion - Whilst the cause of death remains ‘Unascertained’ evidence has been heard that the sleeping environment of Marley on the night of her death presented a more than minimal risk of sudden infant death. The cause of death was established as: I a Unascertained I b I c II

Circumstances of the death

Baby Marley Slack was born on the 22 November 2018 at 31+6 weeks gestation weighing 870 gms. She was the smaller baby of twins. She progressed very slowly and was discharged from hospital on the 06 January 2019 weighing 1550 gms. On the night of the 19 February 2019 Marley was unsettled and was taken into her parents bed beside her father. He woke early in the morning to find Marley not breathing and unresponsive. Cardiopulmonary resuscitation was commenced by dad and continued by paramedics until Marley reached hospital. She was unable to be resuscitated and was declared deceased at Leicester Royal Infirmary on the 20 February 2019.

Action should be taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 April 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons University Hospitals Of Leicester Nhs Trust, Leicestershire Partnership Nhs Trust, and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18). I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Mrs D HOCKING Assistant Coroner for Leicester City and South Leicestershire Dated: 14 February 2020

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Report details

Reference: 2020-0040
Date of report: 14 February 2020
Coroner: Dianne Hocking
Coroner area: Leicester City and South Leicestershire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Apr 2020.

Sent to

Staffordshire, Shropshire and Black Country New born and Maternity Network

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.