Dr Peter Sidebotham is a retired Consultant Paediatrician and Emeritus Professor of Child Health at the University of Warwick’s Medical School. As an academic paediatrician, Peter specialises in child protection and was the designated doctor for child protection and for child death review in Warwickshire.

Peter’s research includes studies on unexpected child deaths including sudden infant death syndrome and work on child death review and child maltreatment. He has worked on several national analyses of Serious Case Reviews, is the author and editor of three books and several book chapters and has published extensively on child abuse and child death reviews.

Peter is a co-editor of the Association’s journal Child Abuse Review. As well as being on the Boards of Trustees for the Association of Child Protection Professionals and the Lullaby Trust

Peter is a member of the National Child Safeguarding Practice Review Panel.

Getting out of our routines: Why preventing sudden unexpected infant death is not just an issue for health visitors and midwives

Over the past thirty years, the UK, in keeping with most other Western countries, has seen a dramatic and sustained drop in the number of sudden unexpected deaths in infancy (SUDI). This has been a really exciting change and has meant that many thousands of infants’ lives have been saved.

In spite of this, over 300 babies die suddenly and unexpectedly each year in England, each of these a devastating tragedy for the family. Many of these deaths are in families who are already struggling with other issues such as poverty, overcrowding, domestic violence or poor mental health.

The National Child Safeguarding Practice Review Panel gets notified of any child who dies or is seriously harmed where abuse or neglect is known or suspected. While – except in very rare cases – abuse or neglect are not thought to have caused the death, a number of cases of SUDI are referred to the Panel because of other concerns. Between June 2018 and August 2019, the deaths of 40 babies were reported to the Panel. Most of these babies died while co-sleeping in bed or on a chair or sofa, often with parents who had consumed drugs or alcohol.

While safer sleep messages may be rigorously delivered by health professionals, for a multitude of reasons many families who are most at risk are unable to act on this advice.

It’s clear that something needs to change in the way all professionals work with these vulnerable families if we are to prevent more infants’ lives being lost through avoidable SUDI.

That’s why our second national child safeguarding practice review explores these areas, drawing on a combination of fieldwork, roundtable discussions and a review of published literature.

The findings show that the best local arrangements for promoting safer sleeping involve a range of professionals as part of a relationship-based programme of support, embedded in wider initiatives to promote infant safety, health and well-being.

For many of these families, events happen which disrupt their normal routines, of their circumstances are such that they just can’t follow the normal safer sleeping advice. Simply giving them a safer sleeping leaflet at a routine post-natal visit isn’t going to be enough to support them in embedding good sleeping practice. We need to learn to listen to them, to understand their circumstances, and to explore with them what can work to minimise the risks to their babies.

This is not just an issue for midwives and health visitors. It’s vital that all child protection professionals working with families who are living with adverse circumstances think about the heightened risks of co-sleeping and work to support parents in making the right choices for their babies.

Our second national child safeguarding practice review picks up on these themes and provides a practice model for local areas to adopt in working with families in whom there are concerns. We are grateful to our reviewers, John Harris and Geoff Debelle for their tireless work in reviewing the cases, and to Anna Pease and the team who carried out the literature review. Read the full report 


It would be great to hear examples of best practice and information on any tools that you have developed, so feel free to share in the comment section below.