Neglect and serious case reviews (PDF, 735KB) - nspcc

Sudi riSKS aNd targeted iNterveNtioN
3. A thematic analysis of neglect
Whilst stating that these deaths were not predictable, these serious case reviews did
allude to missed opportunities to intervene which may have made a difference. Although
the presence of neglect had been recognised, the potentially fatal outcome for the infant
had not. The kind of issues arising are summarised below:
• In one case advice about reducing the risk of SIDS was not formally recorded in
midwifery or health visiting records, so may or may not have been delivered to the
parents.
• Lack of basic health promotion regarding cigarette smoking and SUDI risk, for
example in one case there was no evidence that the ‘reducing risks of cot death’ leaflet
(designed to be given if anyone in household smokes) was given.
• An SCR relating to an incident that took place over the Christmas period highlighted
that although there was a need to be especially alert to alcohol abuse by the parents
and the children being put at risk, there was no evidence of any assessment by the
health visitor in respect of this. The report writer suggests that this should have been
part of the child protection plan.
• In a further example, the health professionals had recognised the possibility of cosleeping
as a potential risk, advice had been given accordingly. However, in this case
professional judgement had been made that the benefits of parental care for the child
outweighed what were understood to be the possible rather than probable dangers of
co-sleeping.
• Another overview report describes how although these issues had been discussed
with the mother, who stated that a Moses basket had been provided for the baby its
existence was not checked, as access to the bedroom was refused. In the event, she
revealed following the baby’s death that he had slept with her.
Sudden infant death is one of the more preventable of child deaths, and indeed since
the ‘Back to Sleep’ campaign of the early 1990s there has been a dramatic reduction
in incidence. However, a higher proportion of residual sudden infant deaths now occur
among more vulnerable families living in areas of high deprivation (Blair et al 2006,
Wood et al 2012). A recent case-control study of SIDS in south west England showed
that many of these deaths occurred in a potentially hazardous sleeping environment,
including sofa sharing with an adult who had recently consumed alcohol or narcotics
(Blair et al 2009). The authors conclude that the major influences on risk ‘are amenable
to change and specific advice needs to be given, particularly on use of alcohol or drugs
before co-sleeping and co-sleeping on a sofa’.
These are new findings and efforts need to be made for this knowledge to become
incorporated into professional practice. One example of innovative work in this respect
is a recent campaign in Lancashire developed in response to the high number of Sudden
Infant Deaths across the county. The campaign centred around safeguarding messages,
aiming to raise awareness of associated risk factors as well as the preventative measures
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