Louie Francis Bradley · Prevention of Future Deaths report

On the 31st August 2017 I commenced an investigation into the death of Louie Francis Bradley, aged 1 day. The investigation concluded at the end of the inquest on the 15th August 2018. The conclusion of the inquest was that he died from Sudden and Unexpected Neo-Natal Death of an Infant born at 42 weeks with widespread pneumonia. The narrative conclusion was as follows:-

On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.

He died following breast feeding in bed with his mother when mother fell asleep.

1. The midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued, this leads to inadvertent co-sleeping and as in this case can lead to death.

2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented.