Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0158, written 23 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2015 |
|---|---|
| Reference | 2015-0158 |
| Deceased | Efan James |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire & Pembrokeshire |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Medical Officer Welsh Assembly Government Cathays Park Cardiff CF10 3NQ 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12th October 2014 I commenced an investigation into the death of Efan Robert James then aged 7 weeks. The investigation concluded at the end of the inquest on 23rd April 2015. The conclusion of the inquest was an open conclusion. 4 CIRCUMSTANCES OF THE DEATH (1) Efan Robert James was placed into a bed his mother was sharing with a friend. Some hours later he was found to be unresponsive. He was administered CPR. He was taken to hospital where life was pronounced extinct. (2) A post-mortem examination was undertaken and the cause of death was given as sudden unexplained death in infancy whilst bed-sharing. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN is as follows: That the advice given by Welsh Assembly Government in the publication “Reduce the risk of cot death” is confusing. It suggests that parents should not share a bed with their baby if they “feel very tired”. Parents of young children will frequently feel tired and gauging whether they are “very tired” is an unrealistic test. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 18th June 2015. 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: 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. 9 23 April 2015 Signed: J M Layton 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Dr Ruth Hussey OBE
Prif Swyddog Meddygol/Cyfarwyddwr Meddygol, GIG Cymru
Chief Medical Officer/Medical Director NHS Wales
Jonathan Mark Layton
Coroners Office
Town Hall
Hamilton Terrace
Milford Haven
SA73 3JW
18th June 2015
Dear Mr Layton
Re: Regulation 28: Report to Prevent Future Deaths issued on 23rd April 2015
in relation to the death of Efan Robert James.
I write in response to your Regulation 28 letter issued on 23rd April 2015 in relation to the death
of Efan Robert James on 12th October 2014. You were concerned about the content of the 2014
Welsh Government guidance leaflet given to parents to reduce the risk of sudden unexpected
death in infancy (SUDI).
The Wales Child Death Review published a report on sudden unexpected infant death in
January 2015 (available at http://www.wales.nhs.uk/sitesplus/888/opendoc/256680). The
report emphasised that these sad events of infant death are a complex problem with many
possible factors. The review concluded that the advice leaflet provided by Welsh Government
was based on the best possible current evidence about minimising risk in the baby’s
environment, and reducing factors contributing to risk. The report emphasised that even when
all the advice is adhered to, sadly there are still some unexplained infant deaths.
This Welsh Government leaflet emphasises the importance of safe sleeping for babies, and
gives overall advice about keeping a smoke free environment, placing the baby to sleep on their
back, on a safe sleeping surface, and avoiding co-sleeping if under the influence of alcohol or
drugs, or when there is a risk of overlaying through parental fatigue. The Welsh Government
advice to parents is consistent with the latest NICE guidance. There is no blanket
recommendation to avoid co-sleeping, as this can interfere with breastfeeding, which is of
course beneficial to the baby and mother. The leaflet clearly identifies when co-sleeping is
inadvisable because of the increased risks of sudden unexpected infant death. The Welsh
Government guidance leaflet should be used and read as a whole.
Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ
Ffon/Tel: 029 2082 3911
Ebost/Email:ruth.hussey@wales.gsi.gov.uk
Following your Regulation 28 letter I asked the Wales Child Death Review team to review the
Welsh Government leaflet in light of your comments. They have concluded that the leaflet
should continue to be used, and they did not recommend any changes to it. They have
reiterated the importance of disseminating the advice mentioned above about how to reduce
the risk of sudden unexpected infant death through safe sleeping practices and maintaining a
smoke free environment. This message continues to be disseminated by primary care health
professionals across Wales. Welsh Government is continuing to explore effective ways of
supporting parents to protect their babies from sudden unexpected infant death.
I have also discussed the matter with other CMOs in the UK and clarified the situation with
regard to NICE guidelines. My understanding is they have no plans to revise the guidance as
there is no new evidence available.
Please do not hesitate to contact me if you require any further information.
Yours sincerely
DR RUTH HUSSEY OBE
CHIEF MEDICAL OFFICER / MEDICAL DIRECTOR NHS WALES
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