Highlighting infant safety on World Patient Safety Day
As the recently appointed RCP clinical director for patient safety and clinical standards, I was pleased to learn that the World Health Organisation theme for World Patient Safety Day 2025 is ‘patient safety from the start’
Paediatricians, our colleagues at the Royal College of Paediatrics and Child Health, the wider multiprofessional team, and of course our own physician members working in paediatrics, are all united in striving to deliver the safest, highest-quality care. Children may not always have a recognisable voice to tell us when something is wrong – which is why it is our duty, as clinicians, to ensure their needs are heard and acted on. The legacy of Martha’s Rule shows the power of listening: one child’s tragic death has transformed how we think about hierarchy, openness, and the agency of patients and families in safeguarding care.
This year, the RCP is shining a spotlight on an important but often overlooked area of risk: the dangers of co-sleeping when parents are prescribed certain medications. Co-sleeping – sharing a sleep surface such as a bed, side-car cot, sofa, or armchair – is well recognised as increasing the risk of sudden infant death when combined with factors like smoking, alcohol, substance use, or drowsiness-inducing medicines. These include antidepressants, mood stabilisers, antipsychotics, sedatives, and opioids. The risk is particularly acute in the first 8 weeks of life
That is why, as physicians, we must take extra care when prescribing and counselling new parents. It is not enough to list side effects in general terms. We must ask whether a patient is breastfeeding, consider their likelihood of co-sleeping – intentionally or otherwise – and explain the real risks these medications can pose to their baby. This should be routine practice across all specialties.
If we do this well, we not only reduce the risk of sudden infant death but strengthen the culture of safety that benefits all patients. World Patient Safety Day is a moment to recommit to that goal – ensuring that from the very start of life, the care we provide keeps children safe and families supported.
For more information about co-sleeping, visit the Lullaby Trust website. This Lullaby Trust recommends that the safest place for a baby to sleep is in their own separate sleep space such as a cot or Moses basket, free from toys, blankets and pillows. This helps lower the risk of sudden infant death syndrome (SIDS).
