Abstract
Aims:
In the UK, Sudden Unexpected Death in Infancy (SUDI) clusters among priority families (those experiencing multiple and complex problems) where universal infant sleep safety guidance is least effective and alternative multi-agency approaches are required. This project implemented and evaluated multi-agency Eyes on the Baby SUDI prevention in Northumberland, a large rural English county.
Methods:
A Steering Group comprising diverse organisations oversaw the programme. The multi-agency workforce was grouped by job roles into three training strands based on frequency and type of contact with priority families. Online training was accessed individually or in teams. Normalisation Process Theory (NPT) supported engagement and embedding SUDI prevention into practice. Pre- and post-training surveys assessed staff knowledge and confidence with SUDI prevention. Follow-up surveys captured staff feedback and engagement at 2, 4 and 12 months post-training.
Results:
Staff in 187 roles across 25 services were recruited; 607 of the 1007 staff registered completed training. SUDI-prevention knowledge and confidence increased across all strands; knowledge remained high 2 and 4 months after completion. Commitment to SUDI prevention was sustained over time. SUDI-prevention champions helped embed learning into everyday practice. At 1 year, 95% of the 73 staff who responded to follow-up remained actively engaged in SUDI prevention. Staff with limited contact with priority families were the least likely to sustain engagement. At the project conclusion, Northumberland County Council adopted the programme for their pan-Northumberland training platform.
Conclusions:
Eyes on the Baby can train and sustain staff engagement in multi-agency SUDI prevention. Key stakeholders with diverse experiences of SUDI prevention oversaw the programme. A Steering Group-led implementation approach encouraged staff to accept SUDI prevention within their roles and was reinforced by team leaders. Early adopters rapidly identified their contribution and engaged enthusiastically as SUDI-prevention champions. One year after training, staff remained engaged, although some roles required additional support.
Plain Language Summary
In the UK, Sudden Unexpected Death in Infancy (known as SUDI) is more likely to happen in families needing extra support. We looked at whether staff from different organisations working in a wide range of jobs across Northumberland would engage with the Eyes on the Baby programme to learn how they could help these families keep their babies safe.
Managers from different organisations oversaw the programme and divided workers into three training groups based on how often and in what ways they had contact with families needing support. Staff completed online training alone or in teams. We used a method called Normalisation Process Theory (NPT) to help get everyone involved in making SUDI prevention a routine part of their work. Surveys completed before and after the training checked staff knowledge about preventing SUDI and confidence in talking to families. Surveys at 2, 4 and 12 months after the training gathered staff feedback.
Staff in 187 roles from 25 services took part. Of 1,007 staff who signed up, 607 finished the training. Their knowledge and confidence about SUDI improved in all areas, and their knowledge stayed high 2 and 4 months later. Their commitment was strong over time. One year later, 95% of staff responding to a follow-up survey were still actively using their training. However, staff who had less contact with high-risk families were less likely to stay engaged. At the end of the project, Northumberland County Council put the training on their county-wide staff training platform.
The Eyes on the Baby programme helps train staff and keep them involved in working together to prevent SUDI. One year after training, staff were still engaged, although some job roles needed extra support to stay involved.
Keywords
Introduction
In the UK, the rates of Sudden Unexpected Death in Infancy (SUDI) have fallen dramatically since the launch of universal infant sleep safety guidance in 1991. 1 Current UK sleep safety guidance informs parents of recommended infant care practices and sleep environments for babies that are associated with lower sudden infant death syndrome (SIDS) and accidental infant death rates. Universal guidance is the provision of this information by midwives and health visitors to all families before and after the birth of a baby. Today, around 300 infants die suddenly and unexpectedly each year in England & Wales (ONS 2022), and SUDI now clusters in the most vulnerable families for whom universal guidance is less effective. 2 Not only do these deaths cluster among families from deprived socioeconomic circumstances, but many families at greatest risk for SUDI are also at risk for a host of other adverse outcomes, including child abuse and neglect. 3 In these cases, complex and hazardous sleep situations for SUDI may involve infants sofa-sharing with a caregiver or sleeping with a parent who has consumed drugs or alcohol, and families sharing the same bed with multiple children in temporary accommodation where no safe infant sleep space is provided. The authors of the 2020 Child Safeguarding Practice Review Panel report note that although universal SUDI-prevention information is rigorously delivered by UK health professionals, many of the families most at-risk are unwilling or unable to receive or act on this information, and that ‘something needs to change in the way we work with these most vulnerable families’ to prevent avoidable SUDI. 3
A 2022 National Child Mortality Database (NCMD) report further emphasised that 42% of unexplained deaths of infants occurred in the most socioeconomically deprived neighbourhoods, with infant mortality rates in the most deprived areas double those in the least deprived areas. 2 A recent commentary highlighted that infant mortality in the UK is rising among vulnerable families, and while government support to reduce socioeconomic determinants of infant mortality is required, this will take time to implement. 4 Meanwhile, the authors argue that innovative interventions targeted at reducing modifiable risks of death for this population are urgently needed, identifying unsafe sleep practices as modifiable factors that have not decreased over two decades. 4 It is therefore increasingly clear that to reduce current infant mortality in the UK, SUDI prevention should be understood as safeguarding work. This work should include partnership working within local areas responding to issues of neglect, social and economic deprivation, domestic violence, parental mental health concerns and substance misuse, as well as disruptions to everyday life known as ‘out of routine’. This requires multi-agency working to extend far beyond the responsibility of health professionals.3,5 Likewise, Pillay et al 4 emphasise the need for public health programmes that connect effectively with vulnerable families, and that ‘should extend to all professionals involved in family and community care’.
Although multi-agency working has been implemented for the investigation of infant deaths since the Kennedy Report, 6 it has only recently been applied to SUDI prevention. There is no guidance for stakeholders wishing to implement multi-agency SUDI-prevention strategies, and only limited examples of good practice exist in the public domain. 5 In 2022–2023, we coproduced a pilot training and intervention programme (TIMP) to target the multi-agency workforce (MAW) SUDI prevention to priority families, in collaboration with stakeholders in County Durham. 7 This became known as the Eyes on the Baby programme, which the MAW enthusiastically adopted but was not subjected to a full and rigorous evaluation due to time and funding constraints. The project reported here aimed to implement the Eyes on the Baby programme in Northumberland and to conduct a robust evaluation to assess staff engagement and sustainability of the initiative beyond the initial implementation phase.
Methods
Ethical approval for this project was received from Durham University Ethics Committee in April 2023. The three local stakeholders involved in this project were Northumberland County Council (Public Health), Northumberland Family Hubs and Northumbria Health Care Trust. A lead representative from each organisation worked with the academic research team to oversee the project. A steering group (SG) was established comprising stakeholders in relevant services from across Northumberland and cross-boundary services. Throughout the project, the SG met monthly to discuss progress, troubleshoot problems and receive updates for dissemination to staff.
The SG determined the scope of the MAW needed to support SUDI prevention targeted to ‘priority families’ in Northumberland, informed by a previous review of MAW SUDI-prevention policies in England. 5 In the UK, priority families are defined as those living with multiple and complex problems, such as unemployment, financial insecurity, risk of homelessness and educational inequality, as well as children at risk from abuse and exploitation and families who are experiencing domestic abuse. A broad role-based approach was taken across the entire county to include the following key multi-agency staff groups:
Staff whose work takes them inside the homes of priority families.
Staff whose roles involve short-term encounters with families with babies or who provide help in a crisis.
Staff who work directly with priority families in any setting.
Healthcare and allied professionals working with adults with vulnerabilities who have babies.
Healthcare professionals who support universal SUDI prevention.
A list of potential job roles to be included was compiled and organised into three core strands comprising staff groups 1 and 2 (Strand 1), staff group 3 (Strand 2) and staff groups 4 and 5 (Strand 3), reflecting graded training and implementation needs. A broad approach was taken to identifying the relevant MAW given the rural and geographically dispersed nature of Northumberland. For example, the SG decided to include Librarians and Birth Registrars under criterion (2), as in some rural communities they were the only NCC staff that new families might encounter who could offer resources and signpost to sources of information.
Training and implementation programme
The Eyes on the Baby TIMP was previously designed and created as an online training and resources package. 7 Three strands of training contained common information about the definition of SUDI, the purpose for infant sleep safety guidance and the core messaging in the ‘Safer Sleep for Babies’ guidance by Lullaby Trust and partners (Lullaby Trust, 2025). The three pre-recorded training strands offered basic (1 × 50 min), intermediate (3 × 30 min) and detailed (3 × 30 min) evidence underpinning safer sleep guidance, the inequities in SUDI outcomes and the need for a multi-agency approach to supporting priority families. 7
All relevant Northumberland-based staff were invited to register for training via managers and team leaders who allocated them to the relevant training strand (July 2023 to December 2023). Where possible, staff were assigned protected time to complete the training and discuss implementation within their teams. Implementation resources relevant to each strand were provided as per the pilot: Strands 1 and 2 received a Decision Tree Tool to help them decide what to do in a particular scenario. Strands 2 and 3 received a list of ‘What if?’ prompts to help them support a family in planning for unexpected events that might mean they are out of routine. Being ‘out of routine’ indicates a disruption to normal life that decreases parental vigilance and increases risk to a baby. 8
Fostering engagement
As in the pilot study, 7 NPT was used to foster the engagement of staff and encourage the embedding of SUDI prevention in their everyday work. NPT is an action theory that supports the analysis of what people do to change their existing practice, rather than focusing on their attitudes or what they believe (Table 1). NPT principles encourage cognitive participation and coherence by supporting the development of communities of practice, encouraging reflexive monitoring and supporting individual and collective sense-making.9,10
The four domains of Normalisation Process Theory (NPT)
To promote engagement using the NPT model, Eyes on the Baby newsletters were sent to all trainees monthly to encourage coherence and cognitive participation. These contained short articles exploring SUDI risks in the context of the job roles from Strands 1 and 2, such as the role of drugs and alcohol in SUDI, mental health issues and SUDI prevention, and the links between domestic abuse and SUDI risk when families are ‘out of routine’. SUDI discussions were held for Stage 1 staff to encourage reflexive monitoring, cognitive participation and coherence, with staff encouraged to ask questions about the training or situations they had encountered. Volunteer SUDI-prevention champions were recruited from across the MAW to support their teams in taking collective action. They were encouraged to raise awareness of SUDI prevention and the Eyes on the Baby training and connect their colleagues with the newsletters and resources. SUDI-prevention champions were offered regular support and guidance via online meetings with the project team and members of the SG.
Assessing uptake, knowledge, confidence and engagement
During project implementation, staff were asked to complete two knowledge and confidence surveys (one pretraining and one post-training), and two surveys about implementing SUDI prevention in practice, 2 and 4 months after completion of training. Training uptake and completion rates were collected and analysed over the course of the project. The follow-up surveys at 2 and 4 months post-training (October 2023 to March 2024) followed the validated NoMAD (Normalisation MeAsure Development) survey format 11 for assessing evidence of coherence, cognitive participation, collective action, and reflexive monitoring, and how SUDI prevention was embedded within the workforce over time. One year later (March 2025), a further staff survey was sent to all MAW staff to assess continued engagement in SUDI prevention.
Results
Training uptake
Staff (n = 1007) from a wide array of services and roles across Northumberland were registered by their managers in one of the three training strands (Table 2). Of the 1007 staff registered for training, 804 (80%) accessed the online learning platform, of which 627 (78%) completed their allocated training (62% of the total registered) (Figure 1). In total, 194 staff were registered for Strand 1, 70% of whom enrolled and 61% completed training. In Strand 2, 473 staff were registered, 77% of whom enrolled and 55% completed training. In Strand 3, 340 staff were registered, 90% of whom enrolled and 72% completed the training.
Registration for Eyes on the Baby by job role
Local authority = Northumberland County Council, NHS = National Health Service (Cumbria, Northumberland, Tyne & Wear NHS Trust; or Northumbria NHS Health Care Trust).
Uptake by staff across training strands
Staff knowledge and confidence
Staff (n = 479) rated their knowledge of SUDI prevention, ability to discuss SUDI prevention with families, ability to spot SUDI risks and ability to take appropriate action on a five-point scale before and after completing the training. Figure 2 shows combined ratings across the four domains compared by strand. Strand 3 staff were expected to have greater knowledge and abilities before training than Strand 1 and Strand 2 staff; even so, there was a substantial increase in scores after training completion across all three strands.
Staff self-reported SUDI knowledge, confidence and ability scores before and after training by strand
At the completion of the training, most staff intended to share the Safer Sleep for Babies leaflets and cards, encourage their colleagues to complete the training and use the checklist to remind themselves of the key risks when supporting families (Figure 3).
Frequency of staff (by strand) intending to build on training in specific ways (n = 497)
Although new to SUDI prevention, 98% of Strand 1 workforce respondents indicated that they understood their SUDI-prevention role, and 96% felt they would be able to use the Eyes on the Baby training (Figure 4). Staff across all three strands responded overwhelmingly positively to questions about their role in SUDI prevention and their understanding of what the Eyes on the Baby project aimed to achieve (Figure 4).
Staff understanding of SUDI prevention and their role (n = 497)
SUDI-prevention champions
Seventeen MAW staff volunteered to be SUDI-prevention champions. They worked with the Northumbria Health Care Trust lead, a Public Health midwife, to ensure that the Eyes on the Baby resources and newsletters were distributed to all staff and to support integration of the programme into everyday practice.
Follow-up survey
Two and four months after completing the training, 277 and 330 staff responded to a follow-up survey (70% of whom responded at both time points) to assess the reality of embedding this new responsibility across a diverse workforce. The responses show that belief in the programme (cognitive participation) remained high across the workforce; reflexive monitoring and coherence varied by training strand and ease of engaging with SUDI prevention, while collective action was rated highly across all strands, indicating staff felt they and management were working together (Figure 5).
Responses to questions from the NOMAD survey at 2 and 4 months post-training
Although they overwhelmingly considered Eyes on the Baby to be worthwhile, some of the staff in Strand 1 found that integration of SUDI prevention in their everyday roles was more difficult than anticipated, as they only infrequently encountered situations where they could put their training into practice. In free-text survey responses, several mentioned speaking to family members and friends who had small babies but not yet sharing the information in a professional capacity. Those who found opportunities to share information with the wider community felt they had been able to do so confidently and effectively (illustrating cognitive participation and coherence): I overheard a conversation of parents after a group, sitting having a coffee talking about the sleeping pods, and I carefully and respectfully joined in the conversation as I sit at an open desk in reception where they were sitting, and asked them did they know about the hazards of these pods and they are not recommended for a baby sleeping. Then all had a general discussion around keeping the cots clear, not using bumpers around the cot and baby sleeping flat in the cot on their back. (Admin staff, Strand 1)
Responses from Strand 2 to free-text survey questions included multiple examples where staff had taken the initiative to share resources and have open conversations about topics such as safe bed-sharing, supporting families to make informed decisions (examples of cognitive participation): When delivering our prevention programme, Brilliant Babies, we discuss safe sleeping in a non-judgmental way. Parents have felt comfortable to share if they do co-sleep so we always share the guidelines for every parent. (Family Practitioner, Strand 2) The Eyes on the Baby training has really helped staff to understand all aspects of safer sleep. It has also given a lot of staff confidence to share how to co-sleep safely with families as we know a number of families will end up in that situation unplanned. (Family Hub Infant Feeding Coordinator, Strand 2)
Staff also reported the programme helped them encourage families to consider contextual factors affecting safer infant sleep. One family health practitioner encountered a family with mental and physical health difficulties where the baby was sleeping in a separate room, and another discussed the risk factors around drinking and bed-sharing (illustrating cognitive participation): [I had an] informal discussion with a parent on coping with disturbed sleep and bringing the baby into bed and looking at alternatives for the husband who had consumed alcohol and using the spare bedroom. (Public Health Nurse, Strand 3)
Staff were also able to reflect on examples of where the training had helped them to correct parental misconceptions. In each case, staff advised against prone sleeping, giving the reasoning behind this guidance which helped the families to make informed decisions (reflexive monitoring): Guidance and information was given to a mum of premature twins who had been thinking about placing one of their babies to sleep on their tummy. She knew this was not advised but did not have an understanding of why. She responded really well to information being shared and this enabled her to come to decision for baby to sleep on their back. (Community Psychiatric Nurse, Strand 3) A lady had thought of putting their young baby on their front to sleep as they thought this would reduce the choking risk. She responded really well to an explanation on the reality that this was not what the evidence had demonstrated and was clear that being given access to all of this information enabled her to rethink and place the baby flat on their back. (Community Psychiatric Nurse, Strand 3)
Overall, the survey responses demonstrated numerous examples of how staff across the multi-agency workforce were able to implement the Eyes on the Baby training and support priority families with safer infant sleep. They had the confidence to embrace opportunities to have meaningful conversations and give up-to-date, evidence-based information on infant sleep safety.
One-year follow-up
The 1-year follow-up survey in March 2025 produced 73 responses from a range of health and care services across Northumberland who had completed Eyes on the Baby training between September 2023 and March 2024 (Table 3); however, some of the original partner services were not represented (e.g. Housing, Domestic Abuse (My Harbour), Drug & Alcohol, Mental Health and Smoking Cessation).
Breakdown of respondents to the 12-month follow-up survey
Of the 73 respondents, 41% had completed training Strand 1, 38% Strand 2 and 21% Strand 3. The vast majority (95%, 69/73) of respondents felt SUDI prevention was, to some extent, now a normal part of their work, with only four responding that it was not (Figure 6). Two of these staff were librarians, and two were family health nursing staff.
Responses to ‘Is SUDI prevention now a normal part of your work?’
Respondents had used the Eyes on the Baby training in multiple ways in their work, the majority supporting parents or colleagues with the information they had learned. Most respondents (81%, 59/73) agreed or strongly agreed with the statement ‘colleagues in my workplace have a shared understanding of the purpose of SUDI prevention’, while 12/73 (16%) neither agreed nor disagreed and 2/73 (3%) respondents strongly disagreed (one admin manager, one registration officer). The majority of respondents (88%, 64/73) also agreed or strongly agreed that staff felt a multi-agency approach to SUDI prevention was worthwhile, while 73% (53/73) felt their management supported staff to implement SUDI prevention. Only 2/73 (3%) respondents (both Library Assistants) felt that MAW SUDI prevention was not at all embedded in their practice area. These responses compared favourably with those from the follow-up surveys 8 and 10 months earlier with evidence of cognitive participation (MAW SUDI prevention being considered worthwhile) falling from 96% to 88%, and collective action (management support for staff implementation) falling from 83% to 77%.
Following the end of the formal TIMP period, the SUDI-prevention champions group, led by the public health matron, continued to work collaboratively to develop family-orientated resources, to maintain and expand connections between organisations, to develop consistent SUDI-prevention messaging across services and to anticipate and react to SUDI issues as they arose in the region while sharing their knowledge and supporting their colleagues in practice. At the 1-year follow-up survey, 61/73 (84%) respondents confirmed they were able to access a SUDI-prevention champion if they needed further advice.
Finally, respondents were asked to report whether they felt MAW SUDI prevention was now effectively embedded in their practice area. Two library assistants felt it was not. Three librarians, 1 registration officer, a 0–19 screener, and an NCC family support worker felt it was slightly embedded, and 90% of staff felt it was embedded somewhat effectively, effectively, or very effectively (Table 4).
Embeddedness of SUDI prevention 1 year after TIMP
Discussion
The multi-agency SUDI-prevention TIMP Eyes on the Baby was successfully implemented in Northumberland. A wide range of staff groups completed and positively evaluated the graded SUDI-prevention training previously developed and piloted, and expressed confidence in delivering SUDI-prevention to the priority families that they encountered as part of their normal roles. In this roll-out, a key priority was to assess staff engagement following training. Over half the staff undertaking training engaged with follow-up, indicating they felt well supported in using their new knowledge and skills to support families with SUDI prevention. Implementation was most challenging for some staff groups in Strand 1 (e.g. librarians, registrars and admin staff) when contact with families was infrequent with little opportunity to put their new learning into practice. However, other individuals in the same roles found valuable opportunities to initiate conversations and signpost families to further information. In future iterations of this TIMP, Strand 1 staff may benefit from a specifically tailored communication strategy to help foster a community of practice, support collective action and sustain engagement with multi-agency SUDI prevention, as their infrequent contact with families should not exclude them from involvement; in isolated rural communities, they may be the only person available at the right place and time to make a difference.
The SUDI-prevention champions programme was a strong example of collective action involving members of all three training strands, sustaining enthusiastic engagement with multi-agency SUDI prevention beyond the end of the formal project and throughout the following year. Future iterations of the Eyes on the Baby TIMP should emulate the Northumberland approach to fostering a champions group. At the end of the research team’s formal involvement in the project in March 2024, ownership of Eyes on the Baby Northumberland was transferred to local leadership and the training strands continue to be available to staff on the NCC Learning Together platform. The SUDI-prevention champions group, led by the Public Health Midwife, continues to produce a regular newsletter on multi-agency SUDI prevention in Northumberland that is distributed to all staff.
The 1-year follow-up survey produced a limited response (11%) in terms of the proportion of staff trained and does not appear to have been cascaded to any of the partner services who participated in the TIMP which, with hindsight, we should have explicitly asked to be done. However, individuals from a broad array of job roles within health and local authority services reported that engagement with multi-agency SUDI-prevention work was ongoing, still considered valuable and had become embedded within the work of multiple teams. Future iterations of the Eyes on the Baby TIMP would benefit from the production of a sustainability action plan at the end of the initial implementation period to formalise the inclusion of SUDI-prevention on team agendas and the reporting of SUDI-prevention activities on a periodic basis to an overall Eyes on the Baby co-ordinator within a safeguarding partnership or local authority public health team.
Challenges and limitations
As in the pilot programme in County Durham 7 , there were challenges in engaging some relevant services in the TIMP, namely GP practices, pharmacies and police. GP practice managers felt that the duration of training (45 min for non-clinical staff, 90 min for clinical staff) was too much given the workload demands on staff; strategic leads in other services failed to respond to the efforts of the SG to engage them. In County Durham, it took 2 years from the end of the pilot implementation to get Eyes on the Baby on the Durham Constabulary’s face-to-face training schedule, suggesting the engagement of some services in a MAW TIMP requires greater lead time than was available here.
Engagement of staff in the evaluation process was also challenging, despite informing staff at the outset that engagement with the programme included completion of follow-up evaluations. SG members invested much time in reminding and nudging staff to complete the surveys with diminishing returns at each wave of evaluation. However, those individuals who did respond provided rich and detailed examples of their SUDI-prevention activities which offer clear evidence of supporting families and are helpful examples for discussion in future training. To boost follow-up response rates, we would encourage service leads to provide dedicated time in staff meetings for completion of the surveys to ensure staff engagement.
Conclusions
We conclude that implementing MAW SUDI prevention is feasible, and Eyes on the Baby offers a tried and tested model for training and engaging MAW staff across a wide array of roles. The use of strategies derived from NPT fostered and sustained MAW engagement for over a year after the end of the TIMP. Further strategies to sustain ongoing engagement were identified. Eyes on the Baby is likely to benefit other local authorities and safeguarding partnerships who wish to implement MAW SUDI prevention for priority families in their local area.
Footnotes
Acknowledgements
The authors are grateful to the members of the project Steering Group and the SUDI-prevention champions without whose help it would have been impossible to deliver this project and to MBDC-Tech who operated the learning platform.
Author Contributions
HLB, SRL-K, MMR and CA designed the project; HLB, MMR and CA managed the project; all authors served on the Steering Group; CA managed the SUDI-prevention champions group; HLB, MMR, SRL-K and LMG drafted the manuscript; all authors reviewed, commented on and approved the manuscript.
Conflict of Interest
The authors declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: Professor H.L.B. has a voluntary role as a member of the Scientific Advisory Group for the Lullaby Trust, the UK’s main SUDI-prevention charity. S.R.L.-K. is the grantholder for a project funded by the Lullaby Trust. The remaining authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research was funded by Northumberland County Council, Northumberland Family Hubs, and Northumbria NHS Health Care Trust via a research contract with Durham University.
Ethical Considerations
Ethical approval for this evaluation was provided by the Durham University Research Ethics Committee in May 2023. Participants completed online surveys and were advised prior to beginning the survey that submission of their responses signified consent to take part in the study.
Data Availability Statement
Anonymised data are available from the corresponding author on request.