Tillie SPENCER-ADAMS · Prevention of Future Deaths report

On 10/04/2019 I commenced an investigation into the death of Tillie SPENCER-ADAMS. The investigation concluded at the end of the inquest 3rd September 2019.

Medical cause of death: Unascertained

Circumstances:
On the 18th June 2018 at around 08:45hrs Tillie Spencer-Adams was found unresponsive by her mother next to her In bed. Tillie was lying on her back, on her mother's bed with her arms above her head, her lips were blue. An ambulance was called and paramedics attempted CPR at the scene. Tillie was then not taken to Lister Hospital where advanced life support continued for around 30 minutes but Tillie could not be revived and her death was confirmed at 10:15hrs. In the period immediately preceding her death Tillie was co-sleeping with her mother. This is a recognised risk factor in infant death but it is not clear whether this caused the death.

Conclusion: Sudden Unexpected Death in Infancy (SUDI)

The matters outlined below were not found to have caused or contributed to the death but do give rise to the relevant concern.

During the course of the investigation it was discovered that on 04/05/18 the mother was involved in a road traffic collision (no third party) and rolled the car, Tillie was in her car seat at the time.

Tillie was checked at Lister Hospital and no injuries were found apart from small mark on her clavicle from the seatbelt. She was discharged the same day,

The post mortem examination on 02/07/19 showed Tillie had sustained fractures to the distal right radius and ulna. Given their close proximity it is likely that these occurred together. In dating the fractures it is plausible that they happened as a result of the reported road traffic collision on 04/05/2018. It is also likely that an old sub-scalp haemorrhage and the old subdural haemorrhage also relate to this road traffic collision.

(1) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she is likely to have suffered serious injuries (fractures and head injuries) which appear to have been overlooked.