Prevention of Future Deaths Report: James Alderman (28 December 2024)

Summary

Baby Jimmy was being breastfed within a baby carrier worn by his mother. After 5 minutes she found that he was collapsed and although immediate resuscitation was commenced he died 3 days later on 11 October 2023 in St George’s Hospital. Jimmy died because his airway was occluded as he was not held in a safe position while within the sling. There is insufficient information available from any source to inform parents of safe positioning of young babies within carriers and in particular in relation to breastfeeding. 

Content

It was accepted that the sling was being worn snugly, not tightly, and although she could see his face when she looked down, the TICKS acronym was not met by his position within the sling as Jimmy was too far down.  

The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers

• tight 
• in view at all times 
• close enough to kiss 
• keep chin off the chest
• supported back.  

There appeared to be no advice in the literature regarding the risk of baby slumping and the risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice that breastfeeding “hands free” a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS. 

There appeared to be no helpful visual images of “safe” versus “unsafe” sling/carrier postures. 

Evidence was given by the witnesses assisting the inquest that public information, readily available, not too complex but consistent in message would be welcomed to advise and instruct. 

Matters of concern

1. There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings 
2. This is notwithstanding a significant increase over recent years in the use of such equipment. 
3. The question of whether it is safe to breastfeed “hands free” is not addressed or referred to in the public domain or manufacturers literature.
4. The NHS available literature provides no guidance or advice.
5. The only current “tips” are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful 
6. Young babies are at risk of suffocation.
7. Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.