Grace Roseman

Dear Ms Schofield, Regulation 28 Reports dated 21 April 2015 and 19 December 2016 We write in response to the two Regulation 28 Reports that you have issued for the Company's attention. Bednest first learnt of the tragic death of Grace Roseman on receipt of your Regulation 28 Report of 21 April 2015. Everyone at Bednest was deeply shocked, saddened and greatly distressed to learn of this tragic incident Bednest repeats its sincere condolences to the Roseman family_ We respond below to points raised in relation to each report in turn. Regulation 28 Reports In your report dated 21 April 2015 ('your first report' ) you identified 6 areas of concern as follows: The manufacturers website clearly shows pictures of babies in these cots with the sides in the incompletely lowered position.
2. The manufacturer s instructions with this cot indicate that a baby should not be left unattended other than when both sides of the bednest are up and secure. In addition any tilt applied to the cot should be restricted to less than 5 cm However this is of little assistance to anyone who has been given a secondhand cot without these instructions readily available. There are no wamings On the cot itself. Should another baby be placed in the prone position and left with the side incompletely lowered again in one of these cots, another death could occur: If the cot side is not safe to be incompletely lowered or for the cot to be tilted more than Scm then it should be questioned as to whether these should be options available at all:
5. These cots are currently available to be purchased through the Bednest Limited Company Number: 05322058 Registered Office: Unit A Drayton Manor Office Buildings Drayton Manor Drive, Stratford upon Avon, CV37 9RQ Telephone: 01926 350197 the being

eeohest manufacturer; NCT and other leading stores There are a large number of second-hand cots being marketed for sale. In the Regulation 28 Report dated 19 December (your second report') , you identified 3 areas of concern: Where Bednest Cribs are still in the hands of customers who unaware of the need to modify the crib. Where customers have the modification kit but still think that it is an optional feature The risk of unmodified cribs passed on or sold in the second hand market Actions Taken We were completely shocked and greatly distressed to learn of this tragic incident from your first report: As a company our ethos is centred entirely on the wellbeing of children and providing a safe environment for infants to sleep. At the time of receipt of your report we had very limited information about what had happened to Grace Roseman: responded swiftly to obtain as much information as possible to inform our decision making; we liaised closely with the regulatory authorities, took expert advice , and implemented appropriate corrective action in conjunction with the regulatory authorities in light of the evolving information and expert evidence. set out below a summary of the action that we have taken: do not have and have never had, any photographs of the Bednest being used with a baby as a free-standing crib with the side in the half-down position. There was one photograph on the website of a mother in bed beside her baby the side in the half-folded position and with the mother's eyes closed We removed this photograph from the website soon after receiving your report. No such photos in the control of the Company have appeared in any Bednest publicity material since then. Following product modifications detailed below, the half fold side feature has been removed; all photographs within our control of the Bednest with the half fold side have been removed as the product no longer has this feature_ 2 The instructions for the Bednest have always been available free of charge from the company to anyone who requested them: An up-to-date instruction booklet is of course sent out every time a Bednest is rented, and with new or ex-rental Bednest sold_ copy of the instructions, in their current form, are also now available by direct download on the Bednest website_ In addition , we have added new warning labels on the Bednest itself and its stand. These include: warning not to use the Bednest without reading the "user
b. An instruction on the side panels of the crib that "both sides must be fully up and secured when baby is unattended or at any time when the crib is free-standing' and warning on the stand to "never raise one end of this stand by more than Scm / 2 inches higher than the other end" together with instructions on how to measure this Bednest Limited Company Number: 05322058 Registered Office: Unit A Drayton Manor Office Buildings, Drayton Manor Drive , Stratford upon Avon, CV37 9RQ Telephone: 01926 350197 are being being We We We with every guide

bechest In light of evolving expert evidence and following consultation with the relevant regulatory authorities, we modified the Bednest Crib in November 2015 so as to remove the "half-down' functionality with the result that the side next to the parental bed can only be fully up or fully down: It is therefore no longer possible for any crib supplied after November 2015, to be left with the side half down. This modification was made on the basis of the "precautionary principle" in light of different opinions expressed by leading paediatricians as to the possibility of a baby able to manoeuvre itself into the type of position in which Grace Roseman was reportedly found. As a company, we took the decision to modify our product on voluntary basis SO as to eliminate any possible risk arising from the half-folding side notwithstanding the differences of opinion between experts and the absence of any reports of incidents of a similar nature in either the UK or US in relation to the millions of bedside sleepers sold with sides of a similar height 5_ The bulk of our business in the UK in recent years has been rental, and we have modified our entire rental stock 6_ In relation to cribs already in the market; we worked in collaboration with Trading Standards, NCT, product recall consultants and product designers, to design a simple self-fit modification kit that safely removes the half-fold capability, along with simple instructions and an online video demonstration that only requires 77 seconds to view. We also take the opportunity to include updated labels in the kit to Bednest up to the latest specification. The kit, and its suitability for home fit by our purchasers, was tested and approved by the leading testing house, FIRA In consultation with Trading Standards, product recall consultants and working with NCT we have endeavoured to directly contact all our customers and all NCT customers, to alert them to the hazard and motivate them to modify their Bednest, and to pass this information to anyone had passed the Bednest to_ This direct contact has consisted of a campaign of repeated emails, and letters for the small number for whom no email address was available We included anybody on relevant databases who had purchased even just replacement mattress or other accessory. NCT conducted a similar campaign to their known customers, as well as to 100,000 members, and passed details to us for follow up_ 8 A RAPEX safety notification (being the appropriate form of regulatory response) was sent out 29th 2016 alerting all EU member states of the risk posed by the half folding site and the modification kit . RAPEX notice was published on the internet including on Trading Standards own sites. 9_ As you are aware, the fact of inquest was very widely reported, before, during and after the inquest: Prior to the inquest; were featured in a number of media outlets, including BBC programme Watchdog, to talk about the tragic death of Grace. We were contacted by these media organisations and alerted them to modification and how this should be obtained. Watchdog has an average audience of 4-Smillion viewers. We also provided details of our modification kit and how this could be obtained for publishing on the Watchdog website: The story was also in The Sunday Times, The Mail on Sunday, The Mirror and The Telegraph amongst other regional news outlets as well as featuring on the BBC website and news App both as a report on the tragic incident and also as a dedicated 'Bednest and safety: what you need to know' article_ In each story details of how the modification kit can be obtained has been publicised . 10 In addition immediately following the Inquest; there was a high volume of press enquiries appeared on ITV's This Morning, Channel 4 evening news, Radio 5 Live, BBC local and national news and ITV news. On each occasion that we were contacted by the press we provided full details of the modification in order to publicise the modification to as wide an audience as possible_ In addition to the television and radio interviews, the modification was publicised in the edition of The Times, The Telegraph, The Daily Mail; Bednest Limited Company Number: 05322058 Registered Office: Unit A Drayton Manor Office Buildings, Drayton Manor Drive , Stratford upon Avon, CV37 9RQ Telephone: 01926 350197 being bring the they July The the print

Bechese The Mirror; The Sun, The Independent; The Guardian and a number of local newspapers as well as appearing in the online versions of those newspapers_ Overall the details of the availability of modification kit has had an audience that we estimate to be tens of millions
11. We have been working with our safety notification expert consultants to identify how best to harness publicity for the benefit of our corrective action campaign in order to maximize the prospects of reaching individuals who might be in possession of an unmodified Bednest crib_ In particular, our campaign has used social media sites, including Facebook, to publicise the warning and modification. Since 28th December this campaign rapidly reached over 225,000 people on Facebook and remains active on the Bednest Facebook page: 12 On 21 December 2016 a further email campaign was launched, following consultation with RQA , Warwickshire and West Sussex Trading Standards, to the entire Bednest database, including all Bednest purchasers and those who had purchased any accessories In this email we warned consumers as to the immediate risk of death if the Bednest was used with the side partially lowered and stated that the Bednest must not be used without the modification kit: The email was sent to people who already had the modification kit and urged them to fit the modification kit if had not already done so_ We have followed up with campaign of repeat sending: We attach a copy of this email (Attachment 1)
13.In our communications customers are offered the option of fitting the modification kit themselves or having the Bednest collected _ modified by us and returned, if they do not wish to apply the modification kit themselves 14_ have consulted with NCT to ensure that its database was also being contacted and that there would be a consistency of message_ We understand that NCT sent a message to all of its database immediately following the Inquest, and they have regularly provided us with details of customers to send kits to
15. Our communications to Bednest and NCT customers regarding the modification kits have also asked them to pass on details of how to obtain the modification kit t anyone to whom they may have given or their Bednest.
16. The first phase of corrective action, in accordance with the advice we received from recall experts, was to supply modification kits to customers who had responded directly to our communications_ The advice we received from recall experts and Trading Standards was that the uptake we received from this first phase was strong by industry standards_ Secondly , following the inquest; we instigated a further email campaign , warning consumers as to the immediate risk of death:
17. Our third phase of corrective action is to send a modification kit to all known purchasers who had not previously requested one. This is a joint action with NCT _ have hired extra staff to enable us to carry this out and we anticipate that we will have completed this third phase, by the end of March 2017 . We attach a copy of the letter which accompanies the modification kit sent from Bednest (Attachment 2).
18. We have a dedicated 24 hour hotline to assist with the supply of modification kits and to deal with any enquiries from consumers about the modification_
19. All rental Bednest cribs have been examined and modified, either by the customer or at source by Bednest staff
20. Purchasers of new replacement mattresses or refurbishments kits receive updated safety warnings about the product;, and we believe we the sole supplier of replacement mattresses. The only previous supplier we are aware of are Little Green Sheep who we believe no longer supply mattresses described as for the Bednest. We are working with Trading Standards to request Little Green Sheep to supply their past customers with the safety notice and appropriate instructions in relation to the modification. Bednest Limited Company Number: 05322058 Registered Office: Unit A Drayton Manor Office Buildings Drayton Manor Drive , Stratford upon Avon, CV37 9RQ Telephone: 01926 350197 the they We sold We are

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21. In addition, prominent information is displayed on our website, including the home page, with easy click- ordering of modification kits_ We have worked with Trading Standards, both before and since the inquest, to ensure that safety notices are in an appropriate form and have been appropriately updated in light of emerging information. We attach a screenshot showing the current homepage of the Bednest website (Attachment 3). As you will see, the safety warning is highly prominent; uses bold and red font and is the first thing anybody would see when visiting the website. The safety warning advises consumers that must not use the Bednest Crib unless it is modified It also advises of the risk of rapid injury or death of using the unmodified Bednest with the side in the half fold position. The Bednest blog and FAQ have similarly been updated as appropriate in light of emerging information and similarly advises that the unmodified Bednest cribs must not be used. We attach a screenshot of our most recent blog post (Attachment 4)_
22. We continue to work with Trading Standards in the daily monitoring of second hand reseller sites on the internet including Ebay, Gumtree and Shpock: Trading Standards have contacted these sites directly advising them not to sell unmodified Bednest cribs have agreed not to list any unmodified Bednest cribs. At present Shpock have also advised that they have stopped the sale of any unmodified Bednest cribs and deleted all historic adverts which relate to unmodified Bednest cribs. contact sellers where the listing is ambiguous to inform that the modification kit must be fitted. Despite assurances above we still keep a regular check on these websites in case some adverts are missed by their monitoring process_
23. We have also liaised with the Charity Retailers Association to inform them of the risk of the half fold side and the modification kit. have included information as to the modification kit in their newsletter and the information on their website
24. Our work with Trading Standards has led us to work with the head of the Institute of Health Visiting about the ways in which Health Visitors who routinely go directly in to the homes of new parents to advise on safe sleep and where appropriate inform them about the modification and the safety risk associated with the half fold side_ The Institute have 6000 health visitors as members but we understand that when publicise on Facebook reach up to around 9000 of the nearly 12000 population of health visitors. Further we been advised that their posts can reach upwards of 50,000 or more interested parties_ attach a copy of their communication to members (Attachment 5).
25. note that you raised the "tilt" option of the crib in your first report. The tilt function was designed to help babies who suffer from reflux We have introduced a new label on the crib which emphasises the maximum tilt and explains how to measure the maximum tilt level in a clear and simple manner: The NHS Choices website recommends some crude ways of baby's sleep surface to help with reflux We believe that the Bednest's bespoke tilt design is safer and more suitable than the uncontrolled and ad hoc alternatives, such as the use of books placed under crib legs or pillow placed under the mattress as advised by NHS Choices: Our design team also informed us that it would be impossible to remove the tilt function from the stand whilst preserving the ability to adjust the Bednest accurately to the same level as the parental mattress which is an important factor in making the Bednest as safe as possible and fit for purpose.
26. Following your first report; NCT suspended all sales of Bednest and it has not been sold by NCT since. The NCT has also closed down its trading arm and no longer markets any baby products at all. Bednest no longer sell to any other retail channels in the UK The Bednest product remains available for renting and purchase from Bednest Ltd in its modified form with additional labelling: Conclusion We have worked at all times in consultation with Trading Standards and product safety and recall experts. By modifying the product and sending modification kit to all known purchasers of the Bednest Limited Company Number: 05322058 Registered Office: Unit A Drayton Manor Office Buildings, Drayton Manor Drive , Stratford upon Avon, CV37 9RQ Telephone: 01926 350197 they Ebay We They put they they have We We tilting

beones Bednest crib, we believe that we have taken the most appropriate and effective corrective action possible. We believe that the corrective action taken also addresses the various issues raised in your Regulation 28 Reports and has achieved the best practical results possible in the field. Our corrective action efforts continue, including on-going monitoring and identification of second-hand users through our replacement mattress sales and the monitoring of on-line private sales. We currently maintain prominent information about the modification kit on our website. Our efforts are ongoing and we are committed to a long term programme of identifying any unmodified Bednest cribs and modifying them as emerge for reuse in the future. Trading Standards are satisfied with our actions and continued cooperation. As a company we are hugely committed to ensuring that effective corrective action continues Bednest Limited believes that it has addressed the issues which you have raised in your Regulation 28 Reports _