Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0040, written 14 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Feb 2020 |
|---|---|
| Reference | 2020-0040 |
| Deceased | Marley Slack |
| Coroner | Dianne Hocking |
| Coroner area | Leicester City and South Leicestershire |
| Category | Child Death (from 2015) · Other related deaths |
| 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 (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Staffordshire, Shropshire and Black Country Newborn and Maternity Network 1 CORONER I am Mrs D HOCKING, Assistant Coroner for the area of Leicester City and South Leicestershire 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 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 4 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. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 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. 9 Mrs D HOCKING Assistant Coroner for Leicester City and South Leicestershire Dated: 14 February 2020
H.M. Coroner
for Leicester City and
South Leicestershire
Professor C.E. Mason
LL.B; BSc HONS; RGN;
DipFMS
The Town Hall
Town Hall Square
Leicester
~ LEl 9BG
1 1 r
Coroners Office:(0116) 454 1030
Email• Leicester.coroner@leicester.gov. uk
Website: http://coroners.leicester.gov.uk
HHJ Lucraft QC
Chief Coroner
Chief Coroner's Office
1 1 t~' Floor Thomas More
Royal Courts of Justice
Strand
London
WC2A 2LL
Reference Number: 00327-2019
29tt' May 2020
Dear Sirs
RE: Marley Hope SLACK
Please note that I have now had a response to my regulation 28 letter sent to the
Staffordshire, Shropshire and Black Country Newborn and Maternity Network. I have
and he has sent me the attached new Pictogram
had a discussion with
indicating that my concerns have been taken into account and thus the development of
the new information which will be an addition to t' he Red Boolc for the area.
I am satisfied that my concerns, have indeed been noted and actioned.
Yours far
Mrs D~iocl{irig ~
Assistant Coroner
Leicester City and S th Leicester
- " ""
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.
l257092 ullaby trust insert card.qxp_Layout 1 27/05/2020 11:20 Page 1 Safer sleep Do... 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 Don’t... Never sleep on a sofa or armchair with your baby 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 Keep your baby smoke free during pregnancy and after birth With kind permission of The Lullaby Trust (see page 15 for further information) Don’t cover your baby’s face or head
See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.