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Learning briefing: Avery – Child death baby under 1

The Incident

Avery was a baby living with their mother and sibling. The ambulance services were called to the house after Avery was found unresponsive. Sadly, ambulance and hospital staff were unable to revive Avery and they died. The cause of Avery’s death is inconclusive but may have been caused by overlaying whilst co-sleeping. Prior to Avery’s death there were allegations raised with both the Police and MASH regarding domestic abuse between their mother and her ex-partner, father to sibling.

Good practice

  • Police responses were timely when concerns were raised. Every report was responded to despite suspicion that reports may have been unfounded, or malicious. Police noted the well-being of the children despite the poor home conditions
  • MASH also investigated some reported concerns
  • Safe sleeping advice was given to Avery’s mother on several occasions by the Neonatal Unit staff, Health Visitors and midwives

Reflection on practice

  • An enquiry was not opened when domestic abuse services made a referral to MASH and subsequently the risk to the unborn baby was not considered
  • The capacity of health staff working in MASH is currently being reviewed to ensure that information is shared from and with health staff to enable professionals to understand the individual needs of babies and children, so that appropriate decisions can be made
  • Although Avery’s history was known by professionals, there was a lack of analysis of the risks and strengths to ensure appropriate support was offered early. More effective utilisation of the Vulnerable Pregnancy Pathway (VPP), including childrens centre resources, could have been conducted to ensure that Avery’s parents received support. Assurance is needed from the midwifery services that their staff possess an awareness about the VPP and the referral route for the childrens centres
  • The midwifery services identified that a bank member of staff did not follow the appropriate referral process for accessing support. The Deputy Head of Midwifery will remind all midwives of the appropriate referral process
  • Information regarding previous concerns was not passed onto Avery’s sibling’s early years setting. This review has highlighted that there is a lack of consistent information sharing between early years settings and CSC, including MASH and Early Help providers
  • Communication regarding keeping babies safe was sent out to professionals and the general public in December 2021. It contains advice regarding coping with crying babies and safe sleep advice.

Messages for practice

  • MASH to consider the needs of unborn babies where concerns are raised about siblings. Unborn babies need to be safeguarded by agencies recognising the impact domestic abuse can have on their well-being and safety
  • All midwives need to know about the Vulnerable Pregnancy Pathway and how to refer to the to the Children’s Centres to provide support to parents to protect their children
  • MASH to request information from early years settings. Children are safeguarded when information is appropriately shared
  • Early years and childcare providers to ensure that they share information when children move to another provider. They should have conversations with parents about the importance of passing on relevant information to a new setting and receiving their consent for information to be shared.


If you are worried about the safety or wellbeing of a child or young person in Devon,
please complete the request for support online form.


If you think that the child is at risk of significant harm,
contact our Front Door directly by calling 0345 155 1071.


In an emergency call 999.