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recurance

Violet Jackman

1 Dec 2020 · Coroner Alison Mutch · Greater Manchester South

The coroner's concerns

  1. 1. inconsistent safe sleeping practice

    “Safe sleeping advice was given to her mother, although it was clear that care would be shared. There was no clear way of ensuring that both parents understood the guidance given or following up that the advice had been shared in detail.”
  2. 2. lack of confirmation of understanding

    “guidance was given as a series of points. The inquest heard that as a general rule, health visitors do not ask parents to explain in a free text style the sleeping arrangements. It is likelv if thev had asked for I such a description, then they would have been made aware of how the guidance had been interpreted and the sleeping arrangement in place. I If they had then the inquest was told that her parents would have been told that the location of the basket was inconsistent with safe sleeping.”
  3. 3. reduced health visitor capacity

    “The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Violet Jackman · Recurance