James Alderman

I am Lydia Brown the Senior Coroner for West London

On 26 October 2023 I commenced an investigation into the death of James Robert Michael ALDERMAN. The investigation concluded at the end of the inquest on 21 November 2024.  The conclusion of the inquest was: Baby Jimmy was being breastfed within a baby carrier worn by his mother. After 5 minutes  she found that he was collapsed and although immediate resuscitation was commenced he died 3 days later on 11 October 2023 in St George’s Hospital. Jimmy died because his  airway was occluded as he was not held in a safe position while within the sling. There is  insufficient information available from any source to inform parents of safe positioning of  young babies within carriers and in particular in relation to breastfeeding. Accidental death 1a Hypoxic Brain Injury 1b Out of Hospital Cardiac Arrest 1c Accidental Suffocation II

The inquest heard that Jimmy was 6 weeks and 6 days old at the time he died, and apart  from a light cold was physically well. He was being breast fed hands free within a baby  carrier/sling, being worn by his mother while she moved around the home. It was accepted  that the sling was being worn snugly, not tightly, and although she could see his face when  she looked down, the TICKS acronym was not met by his position within the sling as Jimmy was too far down. The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers Tight In view at all times Close enough to kiss Keep chin off the chest Supported back There appeared to be no advice in the literature regarding the risk of baby slumping and the  risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice  that breastfeeding “hands free” a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS. There appeared to be no helpful visual images of “safe” versus “unsafe” sling/carrier postures. Evidence was given by the witnesses assisting the inqeust that public information, readily available, not too complex but consistent in message would be welcomed to advise and  instruct.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in  carriers/slings (2) This is notwithstanding a significant increase over recent years in the use of such equipment. (3) The question of whether it is safe to breastfeed “hands free” is not addressed or referred to in the public domain or manufacturers literature. (4) The NHS available literature provides no guidance or advice. (5) The only current “tips” are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful (6) Young babies are at risk of suffocation. (7) Consideration should be given to industry standards to promote the safe use of  slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.