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This month, we’ve published our second review into sudden unexpected death in infancy and started fieldwork on our third national thematic review.
As we forge ahead with our programme of work, we hope this newsletter provides you with up to date information and links to learning and tools to help make improvements to safeguarding practice in your area.

In This Issue

  • Safeguarding Spotlight – How can you adopt and embed good practice to prevent sudden unexpected death in infancy?
  • Third national review into non-accidental injury in babies
  • Register your interest for the Panel’s first webinar
  • Panel Updates – What’s the latest news about the Panel’s reviews and work?
  • Stakeholder News – What recent resources have been published?
  • Have Your Say – Do you want to highlight good practice in your area?
Safeguarding Spotlight

How can you adopt and embed good practice to prevent sudden unexpected death in infancy? 

Last week, our second national review into Sudden Unexpected Death in Infancy (SUDI) was published (Thursday 16 July).
While the overall numbers of babies dying from SUDI are decreasing, a worrying number of these deaths have been notified to the Panel as serious child safeguarding incidents. Between June 2018 and August 2019, the deaths of 40 babies from SUDI were reported to the Panel; most of whom died after co-sleeping in bed or on a chair or sofa, often with parents who have consumed drugs or alcohol.

Sadly, most of these deaths are preventable. The risk factors for SUDI are well recognised, and the steps parents can take to reduce the risk have formed part of the clear, consistent and evidence-based safer sleep messages for years. In spite of this, it is apparent that while the safer sleep messages may be rigorously delivered by health professionals and others, some families are unable to receive or act on the advice.
It seems clear to us that something needs to change in the way we all work with the most vulnerable families if we are to prevent more infants’ lives being lost through avoidable SUDI.
The review has identified a number of issues that have helped inform the development of a ‘prevent and protect’ practice model. We believe this model, if embedded in practice, has the potential to improve the way safeguarding partners work with families to reduce the risks of SUDI, and beyond that, to address a much wider range of risks to their children’s health, safety and development.
The ‘prevent and protect’ practice model has four key components:
  • robust commissioning to promote safer sleeping within a local strategy for improving child health outcomes
  • multi-agency action to address pre- disposing risks of SUDI for all families, with targeted support for families with identified additional needs
  • differentiated and responsive multi-agency practice with families to promote safer sleeping in the context of safeguarding concerns and other situational risks
  • underpinning systems and processes with relevant policies, procedures and practice tools that support effective multi- agency practice across the continuum of risk of SUDI
The model highlights that this issue is not something that can be left solely within the remit of health practitioners or fully addressed by handing out a health promotion leaflet. Rather, it needs to be embedded within respectful and authoritative relationship-based safeguarding practice.

Our hope is that the lessons from this review will be carefully considered by safeguarding partners and by all practitioners working with children and families.
Third national review into non-accidental injury in babies 
Since the Panel’s inception, we have received 198 rapid reviews about babies and young children deliberately harmed or killed (29 June 2018 to 30 June 2020).
This complex and prevalent issue of non-accidental injury can be looked at through many different lenses. However, rapid reviews for these babies often indicate weak risk assessment and poor decision making, often identifying the father or male carer as un-assessed or invisible within the risk assessment process. This means the ability of the father or male carer to be a safe parent, or the risk they presented, was not explored.
That’s why we’ve announced our third national review which will focus on non-accidental injury in babies under 1 year old, with a particular focus on how the safeguarding system works with men (especially those who might present a risk to those children).
The review question asks:
  • Looking at cases of non-accidental injury in infants under the age of 1, how well does the safeguarding system understand the role of the father / male carer?
  • How can the safeguarding system be more effective at engaging, assessing and planning for and with men in the protection of children?  
We have appointed The Fatherhood Institute to undertake a literature review. The three reviewers appointed are Alex Walters, Jenny Myers and Jane Wonnacott, who have begun the fieldwork. A clinical psychologist, Elie Godsi, has also been appointed to understand the drivers and triggers of perpetrators of harm to babies.
The initiation letter and terms of reference for the review can be found on our website here.
Register your interest for the Panel's first webinar
We are updating our Practice Guidance and would like to initiate some discussion with safeguarding partners and partnerships about the variety of learning reviews that are being considered across the country.
That’s why we’re hosting our first webinar on 4th August, 10.00 – 12.30. The webinar will cover recent updates from the Panel, as well as opportunities to contribute to the discussion around Local Child Safeguarding Practice Reviews.
Register your interest here. You will be sent joining instructions, a full agenda and questions for consideration w/c 27 July.
Panel Updates
Stakeholder News

The Principal Children and Families Social Worker (PCFSW) network together with Social Work England have developed a series of good practice guidance in relation to a number of relevant topics for social workers and social care practitioners.
These guides are part of the output from the national digital research and practice development project led by the PCFSW network and further joint guidance in relation to digital professionalism as well as emotional and digital well-being will be released later this month. If you require any further information please contact the national chair: Claudia Megele.
Have Your Say
If you have any feedback on this newsletter, or want to suggest colleagues to add to our mailing list, please don’t hesitate to email us at
We’ve also created a short survey so you can immediately let us know your thoughts.
 Click this link with six questions that can be answered in less than 5 minutes!
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Child Safeguarding Practice Review Panel · Sanctuary Buildings · Great Smith Street · London, London SW1P 3BT · United Kingdom

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