Dear Ms Brown,

Thank you for the Regulation 28 report of 12 December 2024 sent to Department of Health and Social Care (DHSC) about the death of James Robert Michael Alderman (known as Jimmy). I am replying as the Minister with responsibility for public health and prevention, including infant feeding.

Firstly, I would like to say how saddened I was to read of the circumstances of Jimmy’s death and I offer my sincere condolences to the family and loved ones.

Your report sets out several ‘matters of concern’ following your investigation. While the majority of these are outside the scope of my department, my officials have been working closely with colleagues in NHS England and the Office for Product Safety and Standards (OPSS) within the Department for Business and Trade to ensure all of the concerns are being adequately addressed. Each organisation will respond to you separately.

The element of the report that is relevant to my department is the concern that there is a lack of accessible information for parents and carers in the public domain about the use of baby carriers to support ‘hands-free’ breastfeeding.

‘Hands-free breastfeeding’ is not terminology we endorse. Whenever and wherever a baby is breastfed, they will need to be well supported, usually by the mother's arms, hands or body in order that the baby can feed effectively. How this is achieved will depend on the age and development of the baby, the physical characteristics of individual mothers and babies and the relationship between the two. Whilst not an exhaustive list, some breastfeeding positions are shown in this guidance from Better Health Start for Life.

Baby wearing or the use of baby slings may facilitate breastfeeding by helping mother and baby to stay close together. It is the responsibility of baby sling manufacturers to provide clear guidance on the use of their product, including suitability of the product to support breastfeeding and how this can be safely achieved.

Information on a range of topics to support parents is available through the government’s Better Health - Start for Life communication programme, which provides trusted NHS advice and support tailored to users’ stage of pregnancy or baby’s age.

Better Health – Start for Life already includes information about the safe use of baby carriers on its website and in personalised e-mails to parents. In response to your concerns, we are reviewing the information to ensure it is sufficiently prominent. We are also considering ways to supplement the content and engaging with key stakeholders, such as UNICEF UK, to make sure we get the messaging right about the use of baby carriers and breastfeeding. We will also work with NHS England to ensure there is consistent guidance on the use of slings and breastfeeding.

The Better Health – Start for Life website includes a wealth of information about breastfeeding, including guidance on positioning for effective breastfeeding and good latch. While the content does not talk specifically about the use of baby carriers during breastfeeding, it does include information on the importance of ensuring the baby's nose is clear (not obstructed), and the mother observing the baby for signs of effective feeding as well as the baby's general wellbeing.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – James Robert Michael Alderman who died on 11 October 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13 December 2024 concerning the death of James Robert Michael Alderman (known as Jimmy) on 11 October 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jimmy’s parents and family. NHS England are keen to assure the family and the Coroner that the concerns raised in your Report have been listened to and reflected upon, and we commend Jimmy’s parents George and Ellie Alderman for their important work raising public awareness of the risks when using carriers or slings with newborns.

Your Report raised the concern that there is insufficient information available from any source to inform parents of the safe positioning of young babies within carriers / slings and, in particular, in relation to breastfeeding in carriers / slings. NHS England agree that every parent should expect quality, comprehensive advice on how to keep their baby safe, particularly when using products marketed for use with babies.

Advice is available on the NHS.UK website on the safe use of slings – including information on the UK Sling Consortium’s ‘TICKS’ rules, and links to guidance from the Royal Society for the Prevention of Accidents and the Lullaby Trust on baby sling safety – in pages on caring for a newborn baby, and separately on safe sleep and preventing Sudden Infant Death Syndrome. However, on review, NHS England agree that this guidance could be easier to find and isn’t currently linked to breastfeeding information. Our Maternity Team will work with the NHS.UK website team so that guidance on the safe use of slings is easier to find, and is linked to more relevant website pages, such as on breastfeeding.

Turning to antenatal advice given to women in healthcare settings, NHS Maternity Services are required to follow guidance from the National Institute for Health and Care Excellence (NICE), which develops evidence-based guidelines on what advice and care should be routinely provided. We are not aware of specific recommendations or advice on the safe use of slings, and we have referred this issue to NICE for consideration in response to your concerns. We have also passed on the details of this case to UNICEF-UK. As you may be aware, a significant proportion of maternity services in England work to achieve the standards of infant feeding advice and support National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

27 February 2025

set out in UNICEF-UK’s Baby Friendly Initiative, and I know this will be a matter of interest for their trainers and holistic feeding advice.

There are a significant number of products marketed for use with newborns. In the context of limited time for midwives to provide advice in antenatal appointments, NHS England consider that the manufacturers of these products bear a significant responsibility for ensuring that parents receive adequate guidance on their safe use. I note that you have also written to the Office for Product Safety and Standards, and we are supportive of a revised industry standard in this area, in particular around the safe use of slings / carriers while breastfeeding.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jimmy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Brown

We write in response to the Prevention of Future Deaths Report dated 12 December 2024 following the tragic death of baby James (Jimmy) Alderman( case ref 31600472). The report was copied to several of the charities who are signatures to this letter.

We have come together to consider what action we can take following the points raised in your report. As charities with direct contact with new and expectant parents and families we see our role in preventing future deaths as key. We also noted, and share your views, that simple, consistent messaging would help families, and we are committed to supporting that goal wherever possible in our information and services for parents and families.

We are now, together, looking to make rapid change to the guidance for parents around hands-free breastfeeding using slings and carriers, and have agreed that we will tell parents and families, consistently, that this is unsafe and should not be attempted. NCT have already updated their guidance (Baby slings and carriers: a guide | NCT) and I know other organisations here are committed to doing similar.

The Lullaby Trust is currently funding research into sling advice, and taking into account the timings of this project, we have agreed to convene a wider roundtable discussion to agree messaging for parents, families and stakeholders around the use of slings and carriers for young babies that is simpler and consistent. We are going to ensure we include a wide range of researchers and professionals who have contact with families, including breastfeeding experts and leading infant feeding organisations and babywearing professionals, to ensure one aligned message is agreed. We will ensure this includes images and other visual assets that give accurate depictions of using a sling or carrier.

We are all committed to improving the messaging given to families and to learning from the heartbreaking loss of Jimmy.

With best wishes,

Chief Executive, the Lullaby Trust

Chief Executive, CAPT

Chief Executive, NCT

Policy, Campaigns, and Public Affairs Director, RoSPA

Dear Mrs Brown Thank you for your Report to Prevent Future Deaths, dated 12 December 2024, following your investigation and inquest into the tragic death of James Alderman, known as Jimmy, who died on 11 October 2023 from injuries sustained following accidental suffocation whilst in a baby carrier. I was extremely sorry to hear of Jimmy’s tragic death. If you have the opportunity, please extend my deepest sympathies to the family. The Office for Product Safety and Standards (OPSS), within the Department for Business and Trade, is the UK’s national product regulator. Our purpose is to protect people and places from product-related harm, and we take a risk-based approach to our activities. This means we prioritise issues where people who experience vulnerability, such as children, may be at risk. We undertake product sampling and testing of high-risk products and, when necessary, may take action to prevent the supply of dangerous products on the market. OPSS also works with charities such as the Child Accident Prevention Trust and the Lullaby Trust to help raise awareness among parents and healthcare workers of advice that promotes safe use of consumer products aimed at or used by children.

The safety of baby carriers, including soft carriers such as slings, is regulated by the General Product Safety Regulations 2005 (GPSR). These Regulations require that only products which are safe in normal or reasonably foreseeable use can be placed on the market. They also place obligations on manufacturers and importers to make sure the products they supply are safe, to consider any risks that may arise from the product in normal or foreseeable use, and to take action to avoid or mitigate against them. This includes providing appropriate warnings relating to any risks the product may pose during its use, and supplying any instructions that may be needed for the product to be used safely. Product distributors must pass on any such warnings or instructions with a

OFFICIAL-SENSITIVE OFFICIAL-SENSITIVE product, whether it is for loan, rent or sale. Both OPSS and Local Authority Trading Standards have powers to enforce the regulations. There is also a voluntary standard EN 13209-2:2015 (Child use and care articles - Baby carriers - Safety requirements and test methods - Part 2: Soft carrier), which is designated by the Government under GPSR, meaning goods produced in line with the standard are presumed to comply with those Regulations. Merton Council Trading Standards are leading the investigation into the circumstances of this case, and on communication with the business that supplied the product, as they are based in the London Borough of Merton. We understand that the manufacturer of the product is based outside the UK. Initial intelligence gathering by OPSS has indicated that the product cites compliance with an earlier version of the standard for these types of products, which is not designated by Government. These matters will be the subject of investigation as to whether the product was compliant with the relevant regulations at the time of supply.

You also raise matters of concern regarding the availability and promotion of advice on the use of baby carriers and breastfeeding. I understand that the Department for Health and Social Care and NHS England will write to you separately on this issue. Should there be any updates to Government or NHS advice regarding the safety of infants when in a baby sling or carrier, OPSS will bring this to the attention of relevant trade associations, including the Baby Products Industry Association. OPSS would also review the designation of the voluntary standard, to consider whether any amendments, accompanying notes or restrictions to the standard may be required. Changes to the standard itself would be a matter for the British Standards Institution, who I understand also received a copy of your Report. It will remain businesses’ responsibility to ensure that their product instructions for safe use take account of the latest safety advice. Thank you for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with any of your colleagues who may find it useful. Kind regards, Chief Executive Office for Product Safety and Standards