Violet Jackman
PFD Report
All Responded
Ref: 2020-0263
All 1 response received
· Deadline: 1 Mar 2021
Coroner's Concerns (AI summary)
Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.
View full coroner's concerns
1. Safe sleeping advice was given to her mother, although it was clear that care would be shared. There was no clear way of ensuring that both parents understood the guidance given or following up that the advice had been shared in detail.
2. The guidance was given as a series of points. The inquest heard that as a general rule, health visitors do not ask parents to explain in a free text style the sleeping arrangements. It is likelv if thev had asked for such a description, then they would have been made aware of how the I I guidance had been interpreted and the sleeping arrangement in place. If they had then the inquest was told that her parents would have been told that the location of the basket was inconsistent with safe sleeping.
3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken, or if Health Visitor services were being reduced to support other front line services.
2. The guidance was given as a series of points. The inquest heard that as a general rule, health visitors do not ask parents to explain in a free text style the sleeping arrangements. It is likelv if thev had asked for such a description, then they would have been made aware of how the I I guidance had been interpreted and the sleeping arrangement in place. If they had then the inquest was told that her parents would have been told that the location of the basket was inconsistent with safe sleeping.
3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken, or if Health Visitor services were being reduced to support other front line services.
Responses
Noted
The DHSC outlines existing guidance, training and resources related to safe sleeping for infants, including collaboration with Public Health England and the Lullaby Trust. It also notes advice given to local authorities during the pandemic regarding prioritizing health visitor services and awaits a report from the Early Years Health Advisor. (AI summary)
The DHSC outlines existing guidance, training and resources related to safe sleeping for infants, including collaboration with Public Health England and the Lullaby Trust. It also notes advice given to local authorities during the pandemic regarding prioritizing health visitor services and awaits a report from the Early Years Health Advisor. (AI summary)
View full response
Dear Ms Mutch,
Thank you for your letter of 1st December 2020 to Secretary of State, Matt Hancock, relating to the death of Violet Leona Jackman. I am responding as minister responsible for health visiting services.
I have noted carefully your concerns about the guidance parents receive regarding safe sleeping, how health visitors ensure the guidance has been interpreted correctly by the parents, and the redeployment of health visitors during the pandemic.
Firstly, I would like to offer my sincere condolences to the parents and family of baby Violet. I can appreciate how deeply distressing Violet’s death must be for them. I wish to assure you that we recognise the need to support professionals working with mothers and fathers to provide sensitive and attuned parenting, particularly during the first month and years of life, giving individual tailored support for the child and its parents or carers. That way, we can prevent problems from arising in the first place, rather than dealing with the consequences. It is distressing that some infants suffer serious harm or even death as a result of unsafe sleeping arrangements, and every case is a tragedy. We are determined to do everything we can to prevent these deaths. Discussions with parents about safe sleeping are part of antenatal and post-natal support offered by health visitors. We know health visitors and midwives are a trusted resource for parents. Public Health England (PHE) has also produced with the Lullaby Trust advice on how parents can reduce the risk of sudden infant death syndrome (SIDS) [1]. Fathers have an equally vital role during pregnancy and throughout their child’s life and the first few weeks and months are critical. We will continue to provide health visitors and their teams with evidence and advice on how to ensure both fathers and mothers are supported to adapt to parenthood and engaged in the care of their child.
1 https://www.lullabytrust.org.uk/safer-sleep-advice/
We will also continue to embed learning from the Child Safeguarding Practice Review Panel report on sudden unexpected death in infancy [2]. With Ministerial colleagues in the Department for Education (DfE) and Home Office, we have welcomed the report’s recommendations. The report highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:
• The Child Safeguarding Practice Review Panel and DfE to work with the Department of Health and Social Care (DHSC), NHS England, and the National Child Mortality Database to explore how data collected through child death reviews can be crossed-checked against those collected through serious incident notifications to support local and national learning;
• As part of the refresh of the high impact areas in the Healthy Child Programme (HCP) and the specification for health visiting, Public Health England should consider how the learning from this review can be better implemented in advice and guidance to help new parents and during a baby’s early weeks, including considering allowing parents to explain in free text style; and,
• DHSC to work with key stakeholders to develop shared tools and processes to support front-line professionals from all agencies in working with families with children at risk to promote safer sleeping as part of the wider initiatives around infant safety, health and wellbeing. In relation to the redeployment of Health Visitors during the pandemic, some public health nurses were redeployed. This varied across the country with some services continuing to deliver the full range of HCP interventions. On 19 March 2020 NHS England and NHS Improvement (NHSE/I) published national guidance, agreed with Public Health England (PHE) and the Local Government Association (LGA), on community service prioritisation and restoration of community health services. Subsequent iterations of the guidance have since been published, most recently on 18 September 2020[3]. All services were advised to follow this guidance, which made it clear that health visitor services should be prioritised, with face to face contacts being adapted to ensure COVID- 19 guidelines were followed.
[2] https://www.gov.uk/government/publications/safeguarding-children-at-risk-from-sudden-unexpected-infant-death 3 https://www.england.nhs.uk/coronavirus/publication/covid-19-prioritisation-within-community-health-services- with-annex_19-march-2020/
In response to growing concerns regarding the potential for re-deployment of Health Visitors in a second wave, PHE, NHSE/I and the LGA provided further advice to Directors of Nursing in October 2020 [4].
The advice reinforced the original guidance and stated that professionals, including Health Visitors, supporting children with special needs should not be redeployed to other services except in individual circumstances and for the shortest time possible.
I am pleased Chief Nurses together with the LGA have recommended this frontline support is maintained through the winter and have committed to not redeploying Health Visitors over the winter.
Finally, we are awaiting a report from the Early Years Health Adviser, Andrea Leadsom MP, who has been leading a major review into improving health outcomes in babies and young children [5]. The review will consider the barriers that impact on early-years development, including social and emotional factors and early childhood experiences, and seek to show how to reduce the impacts of vulnerability and adverse childhood experiences in this stage of life. I hope this information is helpful and demonstrates the range of action being taken to raise awareness and target action to prevent the risk of future tragic deaths such as that of Violet. Thank you for bringing these concerns to my attention.
JO CHURCHILL
4 https://ihv.org.uk/wp-content/uploads/2020/10/Letter-R.E-HVs-and-SNs.pdf 5 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches
Thank you for your letter of 1st December 2020 to Secretary of State, Matt Hancock, relating to the death of Violet Leona Jackman. I am responding as minister responsible for health visiting services.
I have noted carefully your concerns about the guidance parents receive regarding safe sleeping, how health visitors ensure the guidance has been interpreted correctly by the parents, and the redeployment of health visitors during the pandemic.
Firstly, I would like to offer my sincere condolences to the parents and family of baby Violet. I can appreciate how deeply distressing Violet’s death must be for them. I wish to assure you that we recognise the need to support professionals working with mothers and fathers to provide sensitive and attuned parenting, particularly during the first month and years of life, giving individual tailored support for the child and its parents or carers. That way, we can prevent problems from arising in the first place, rather than dealing with the consequences. It is distressing that some infants suffer serious harm or even death as a result of unsafe sleeping arrangements, and every case is a tragedy. We are determined to do everything we can to prevent these deaths. Discussions with parents about safe sleeping are part of antenatal and post-natal support offered by health visitors. We know health visitors and midwives are a trusted resource for parents. Public Health England (PHE) has also produced with the Lullaby Trust advice on how parents can reduce the risk of sudden infant death syndrome (SIDS) [1]. Fathers have an equally vital role during pregnancy and throughout their child’s life and the first few weeks and months are critical. We will continue to provide health visitors and their teams with evidence and advice on how to ensure both fathers and mothers are supported to adapt to parenthood and engaged in the care of their child.
1 https://www.lullabytrust.org.uk/safer-sleep-advice/
We will also continue to embed learning from the Child Safeguarding Practice Review Panel report on sudden unexpected death in infancy [2]. With Ministerial colleagues in the Department for Education (DfE) and Home Office, we have welcomed the report’s recommendations. The report highlights that despite broad success embedding safer sleeping messages with parents, there are still persistent issues for some families when it comes to acting on those lessons. The report is clear that this is a complex issue. We will implement the three national recommendations:
• The Child Safeguarding Practice Review Panel and DfE to work with the Department of Health and Social Care (DHSC), NHS England, and the National Child Mortality Database to explore how data collected through child death reviews can be crossed-checked against those collected through serious incident notifications to support local and national learning;
• As part of the refresh of the high impact areas in the Healthy Child Programme (HCP) and the specification for health visiting, Public Health England should consider how the learning from this review can be better implemented in advice and guidance to help new parents and during a baby’s early weeks, including considering allowing parents to explain in free text style; and,
• DHSC to work with key stakeholders to develop shared tools and processes to support front-line professionals from all agencies in working with families with children at risk to promote safer sleeping as part of the wider initiatives around infant safety, health and wellbeing. In relation to the redeployment of Health Visitors during the pandemic, some public health nurses were redeployed. This varied across the country with some services continuing to deliver the full range of HCP interventions. On 19 March 2020 NHS England and NHS Improvement (NHSE/I) published national guidance, agreed with Public Health England (PHE) and the Local Government Association (LGA), on community service prioritisation and restoration of community health services. Subsequent iterations of the guidance have since been published, most recently on 18 September 2020[3]. All services were advised to follow this guidance, which made it clear that health visitor services should be prioritised, with face to face contacts being adapted to ensure COVID- 19 guidelines were followed.
[2] https://www.gov.uk/government/publications/safeguarding-children-at-risk-from-sudden-unexpected-infant-death 3 https://www.england.nhs.uk/coronavirus/publication/covid-19-prioritisation-within-community-health-services- with-annex_19-march-2020/
In response to growing concerns regarding the potential for re-deployment of Health Visitors in a second wave, PHE, NHSE/I and the LGA provided further advice to Directors of Nursing in October 2020 [4].
The advice reinforced the original guidance and stated that professionals, including Health Visitors, supporting children with special needs should not be redeployed to other services except in individual circumstances and for the shortest time possible.
I am pleased Chief Nurses together with the LGA have recommended this frontline support is maintained through the winter and have committed to not redeploying Health Visitors over the winter.
Finally, we are awaiting a report from the Early Years Health Adviser, Andrea Leadsom MP, who has been leading a major review into improving health outcomes in babies and young children [5]. The review will consider the barriers that impact on early-years development, including social and emotional factors and early childhood experiences, and seek to show how to reduce the impacts of vulnerability and adverse childhood experiences in this stage of life. I hope this information is helpful and demonstrates the range of action being taken to raise awareness and target action to prevent the risk of future tragic deaths such as that of Violet. Thank you for bringing these concerns to my attention.
JO CHURCHILL
4 https://ihv.org.uk/wp-content/uploads/2020/10/Letter-R.E-HVs-and-SNs.pdf 5 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
1 Mar 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18th May 2020 I commenced an investigation into the death of Violet Leona Jackman .The investigation concluded on the 18th November 2020 and the conclusion was one of Narrative: Sudden and unexpected death of a baby where a Moses basket overturned whilst she was asleep in it. The medical cause of death was 1a) Sudden unexpected death in a child with mild lower respiratory tract infection, associated with an accidental unsafe sleeping position
Circumstances of the Death
Violet Jackman was a baby who initially lived with both her parents and then after they separated, care was shared. Following her birth, the initial Health Visitor visit took place in accordance with usual practice. Safe sleeping advice was given to her mother who was present. On 17th May~ was found unresponsive on a bed at her home address, ~ Ill. The Moses basket in which she had been sleeping had tipped over.
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