Dear Ms Hassell Re: Regulation 28 Report to Prevent Future Deaths – Rifky Grossberger who died on 5 August 2019. Thank you for your Regulation 28 Report (hereafter the ‘report’) dated 11 March 2020 concerning the tragic death of Rifky Grossberger on 5 August 2019. Firstly, I would like to express my deep condolences to Rifky’s family and all those touched by her death. Your report concludes that Rifky’s death was a result of an accident. Her medical causes of death were hypoxia and asphyxia. Following the inquest, you asked NHS England and Improvement (hereafter ‘NHSEI’) to address your concern regarding the need to find methods of delivering safety advice in an easily accessible format. This could be in the form of local and national leaflets to provide parents with the safety advice they need to look after their new born baby. There is advice available on the NHS Choices website on ligature risks

specifically mentions blind safety. You also asked NHSEI to address your concern around the need for healthcare professionals such as midwives and district nurses who look after new mums and their babies to be reminded of this particular danger. We have consulted with Public Health England (hereafter ‘PHE’) who have advised that the national Healthy Child Programme (HCP) published by the Department of Health and Social Care, the universal public health programme for 0-19 year olds and their parents/carers, recommends that home safety information is discussed with families from birth and throughout the first 5 years. The Healthy Child Programme (0-
5) is led and delivered by Health visitors. Health visitors are specialist public health nurses, who are the lead professionals working with children 0-5 years. They deliver Professor Stephen Powis National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 27th May 2020

evidence based public health interventions and are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. Health visitors deliver the five mandated health reviews which include:
• 28/40 weeks of pregnancy
• 10-14 days post birth
• 6-8 weeks
• 1 year
• 2.5 years

PHE sets out more specific guidance on the role of the health visitor in the Six High Impact Areas which support local delivery of the HCP. High Impact Area five focuses on managing minor illnesses, reducing accidents and outlines how health visitors provide evidence-based safety advice to parents, including through child health clinics, baby groups and other parenting activities. PHE has worked with the RoSPA and CAPT to publish a report on reducing unintentional injuries in and around the home among children in 2018. This highlighted the most prevalent causes of unintentional injury hospital admissions and preventable death and serious long-term harm, including strangulation, and made recommendations around accident prevention at the local level. Moving forward, PHE has outlined an aim to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025). It aims to achieve this through the modernisation of the Healthy Child Programme which is taking place between 2020-2023. 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 Mr Hassell

Re: Regulation 28 Prevention of Future Deaths report - Rifky Grossberger (died
05.08.19)

This letter is in response to your request to Regulation 28: Prevention of Future Deaths report that was received by the Royal College of Nursing on March16th
2020. I am sorry to hear about the tragic circumstances relating to the death of Rifky Grossberger.

Your report states that ‘ … the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger.’ In preparing this response, we have consulted with our members that span our range of Children and Young People Forums, and our Professional Leads for Public Health, Midwifery, Children & Young People and Primary Care.

Midwives and Health Visitors routinely provide new parents with written information about a range of issues, including safety in the home. Discussions around safety is an integral part of the national Healthy Child Programme of contacts with the family, that is undertaken by the Health Visitor throughout the child’s early years.

Royal College of Nursing 20 Cavendish Square London W1G 0RN Dame Donna Kinnair Chief Executive & General Secretary Telephone 020 7647 3781 Email

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The Healthy Child Programme for the early life stages focuses on a universal preventative service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. The safety aspects of discussions with parents includes the potential risk of strangulation and suffocation, with Health Visitors highlighting and providing resources from the Child Accident Prevention Trusti and NHS online advice for new parentsii.

In considering your report, we have reviewed and strengthened our guidance about the potential risks of strangulation and suffocation on our clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. Further to this, we have also brought this matter to the attention of our members through Forums and their social media platforms.

I trust that our response gives some assurance that safety advice is an integral part of the Healthy Child Programme, and highlights the steps that the Royal College of Nursing has taken to bring this issue to the attention of our members who provide care to babies, children and their families.