Our training and resources

Learning briefing: Evie (2026)

Purpose

This briefing aims to provide a concise overview for multi-agency practitioners and team managers, highlighting key areas of good practice and areas for improvement.

The incident

Evie was a 3-month-old infant, who was found unresponsive at home and sadly died. Information gathered during the review identified several sleep-related risk factors. The review found that agencies had been appropriately involved with the family and that safeguarding concerns had not previously been identified.

Good practice

  • The family received consistent support from Midwifery, Health Visiting, GP and neonatal services, with good communication and continuity of care across agencies. Additional support was provided through antenatal Health Visiting contacts, growth monitoring and feeding support.
  • Safe sleep and ICON messages were delivered on multiple occasions through verbal discussions, written information and routine professional contacts.
  • Maternal mental health needs were identified early, explored throughout the perinatal period and reviewed appropriately by services, with additional support offered when required.
  • The review found evidence of appropriate clinical assessment, professional curiosity and responsive care throughout the maternity, neonatal and postnatal pathways.

Messages for practice

  • Safer Sleep is a shared responsibility across the whole children’s workforce. Whatever your role or agency, every contact counts. We should use routine interactions with babies, children and families to promote safer sleep, reinforce key messages and ensure advice is tailored to the family’s individual circumstances.
  • Providing information is only part of the safeguarding response. You should not assume that sharing safer sleep advice alone will reduce risk. If we take time to understand how parents interpret, remember and apply safer sleep messages in their everyday lives, we can make sure any ongoing discussions include sleep arrangements, parental fatigue, medication use, alcohol consumption, support networks and any other factors that may increase risk.
  • Good recording is essential. Our records should not only capture discussions that took place, but also parental understanding, our professional assessment, questions raised and the rationale for decision-making.
  • The involvement of fathers, partners and wider family members should be visible in assessments and records. Their understanding, views, support needs and networks can provide us with important context when assessing family strengths and vulnerabilities.
  • Professional curiosity should be used to consider individual concerns and explore how a range of pressures and challenges may combine to affect a family’s wellbeing and increase risk. This may include factors such as parental wellbeing, anxiety, sleep deprivation, medication use and changing family circumstances.

What can we do next?

  • Keep reinforcing safer sleep and ICON messages, using language and approaches that parents can understand and apply.
  • Take every opportunity to discuss co-sleeping, parental fatigue, medication use, alcohol consumption and changing sleep arrangements with anyone who has caring responsibilities for a baby.
  • If you prescribe or review medication which can cause drowsiness, you should routinely consider and discuss safer sleep risks with all carers of infants under 12 months.
  • Make sure recording systems and our practice include key conversations, assessments and parental responses to clearly support continuity of care and identify the build-up of factors that may affect a family’s wellbeing.
  • So that parents and carers understand risks and can make informed decisions about safe sleep environments, we need to personalise safer sleep discussions to each family’s individual circumstances, vulnerabilities and risk factors.
  • Make sure fathers, partners and wider family members are actively involved in assessments, planning and discussions, and that their views, understanding and support needs are clearly recorded.

Key learning

Safer sleep messages were shared consistently and appropriately. However, keeping babies safe is about more than giving information. We need to understand how families make sense of the advice we give them and how they build it into their everyday life. By having meaningful conversations, being professionally curious and keeping clear records, we will better understand family circumstances, identify risks early and support families to make safer choices for their baby.

Discuss, reflect and act

Please use this briefing, along with the resources below, within team meetings, safeguarding supervisions and reflective discussions. Consider how the learning from this review applies to your own practice, service and agency procedures and whether you have identified any learning needs.

Download a printable PDF of this learning briefing

If you are worried about the safety or wellbeing of a child or young person in Devon, please make a request for support or report a child safety concern.

 

In an emergency call 999.


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