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Investigation and inquest
On 10th April 2015 I commenced an investigation into the death of Grace Joy Roseman. The investigation concluded after a three day inquest held between the 14th to 16th December 2016. The conclusion of the Inquest was Accidental Death.
Circumstances of the death
1. Grace Joy Roseman was born on 18th February 2015 at 41 weeks and 4 days.
2. A few months before she was born (in late November/Early December 2015) her parents were given a secondhand NCT Bednest crib. The crib did not come with any written instructions and there were no instructions on the crib itself.
3. The crib was manufactured by Bednest but was cobranded with NCT and bore the label NCT Bednest, Before being marketed it had been passed as compliant by the FIFA test house in relation to BS EN 1130 standard.
4. Having been given the crib ████████ decided that she wanted her own mattress and purchased the “Little Green Sheep” mattress, which met the size specifications stipulated by Bednest, through the NCT website.
5. When Grace was born it became clear that she disliked sleeping on her back so ████████ had to resort to placing Grace in the prone position when she started sleeping in the crib. As a safety measure her husband placed a breathing pad under the mattress.
6. ████████ always used the crib with one of the sides of the crib (the side closest to the bed) in its half lowered position. At no time did she realise that it would be unsafe to do so.
7. On 9th April 2015 Grace was put to sleep in her NCT Bednest crib following an early morning feed. Her mother again placed her in the prone position. Sometime after 6.30 am ████████ went downstairs with her other daughter ████████ At around 8.30 she came back upstairs but Grace was still asleep. Not wanting to disturb her Mrs Roseman went back downstairs.
8. At around 10.00, after having a bath, ████████ went into the room where Grace was sleeping. There she found Grace lying sideways with her head over the half lowered side wall of the Cot. The right side of her head and neck was purple.
9. ████████ immediately took Grace to the hospital (which was very close by) but sadly the Doctors were unable to revive her.
10. Following her death a Post Mortem examination was undertaken by ████████ and the medical cause of death given was postural asphyxia. Following evidence at the Inquest the cause of death was amended to pressure on the carotid sinus leading to positional asphyxia.
11. During the Inquest four experts were called to give evidence and they were all satisfied that, despite her age, it would have been possible for Grace to have got her head over the half lowered side of the crib. They also agreed that once in this position she would not have been able to remove herself from it.
12. Despite the certification that had been provided by FIRA the experts instructed by Trading Standards, who gave evidence at the hearing, took the view that the product was unsafe when being used with the half folded down side, whether or not the infant was being supervised.
13. Since Grace’s death Bednest have modified the crib so that the sides can no longer be lowered into a half way position. They have tried to contact as many of their customers as they can and where requested they have sent out modification kits to these customers
Coroner’s concerns
(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side.
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification. In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
Information checked against the published report and official responses