In its latest report, Out of routine: a review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm, the Child Safeguarding Practice Review Panel says many of these children are also considered at significant risk of harm.
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Of 568 serious incidents reported between June 2018 and August 2019, 40 involved infants who had died suddenly and unexpectedly, the majority of which involved babies under three months old.
Around half of the infants that died were male (53 per cent) with a peak in deaths for those children aged one month (15 cases).
Almost all of these incidents involved parents co-sleeping in unsafe sleep environments with infants, often after drugs or alcohol had been consumed, the report states.
There were wider safeguarding concerns around these families, often involving cumulative neglect, domestic violence, parental mental health concerns and substance misuse, it adds.
The panel is calling for a change in how practitioners work with these vulnerable families to prevent more infants lives being lost through avoidable SUDI.
“The major risk factors for SUDI are well known and the advice on reducing the risks is evidence-based and well established.
“In spite of this, it was apparent from the cases notified to the panel that this advice, for whatever reason, is not clearly received or not acted on by some of those families most at risk,” the report concludes.
For these groups of families, the risk to their children extends beyond the direct risks of abuse or neglect to include wider risks to their health, development and wellbeing, it adds.
It recommends embedding wider strategies for responding to neglect, issues related to deprivation, domestic violence and parental mental health concerns and substance misuse in multi-agency working, not just leaving it to the responsibility of health professionals.
The use of behavioural insights and models of behavioural change should also be investigated to explore whether these can support interventions to promote safer sleeping, specifically with families with children at risk of significant harm.
Responding to the panel’s findings, the Association of Directors of Children’s Services (ADCS), said more work was needed with parents, particularly the most vulnerable, to prevent incidences of SUDI occurring and to address a wider range of risks to children’s health and safety.
Charlotte Ramsden, ADCS vice president, said: “We welcome the emphasis on the importance of differentiated and responsive multi-agency practice as this is the core of all effective safeguarding work.
“We know that the impact of Covid-19 is exacerbating many of these risk factors for families which makes the report’s findings even more important.”
