Savannah-Rose Michelle Owen · Prevention of Future Deaths report

On 23rd April 2018 I commenced an investigation into the death of Savannah-Rose Michelle Owen. The investigation concluded on 7th November 2018 and the conclusion was one of Natural Causes.

The medical cause of death was 1a) Unascertained

Savannah-Rose Michelle Owen was a healthy baby born on 16th February 2018. On 22nd April 2018 she fell asleep on a nursing pillow on the sofa at her home address. Her parents realised she had become unresponsive and an ambulance was called. Attempts to resuscitate her were unsuccessful. A post-mortem did not find a cause of death but did exclude any third party involvement or suspicious circumstances and on the balance of probabilities would have been due to natural causes.

The inquest heard that:
Savannah-Rose’s mother had purchased the multi-purpose nursing pillow from a well-known supermarket chain. There were warnings about its use on a card that came with the pillow but was not attached to it. On the warning/information leaflet were 5 pictures of a baby positioned on the pillow. In only 2 images was the baby with an adult. On the other 3 the baby was alone.
The inquest heard that sleeping unsupervised on such pillows was not consistent with the safe sleeping advice given to new parents. However:

1. Unlike many items associated with babies/young children such as high chairs/cots there was no specific safety regulation for such items. Instead manufacturers had to interpret the all-embracing safety policy. This risked inconsistent safety warnings/labelling;

2. It was unclear if Health Visitors/ Midwives in the community seeing multi-use pillows being used were flagging up the risks of allowing babies to be propped on them for naps and that their use in such a way was wholly inconsistent with safe sleeping advice;

3. On the warning/information leaflet were 5 pictures of a baby positioned on the pillow. In only 2 images was the baby with an adult. On the other 3 the baby was alone. The inquest was told that this could be misleading as to the importance of never leaving a baby unattended on the pillow; and

4. The warning label was not attached to the item therefore; once the package had been opened, there was a high risk that the warning label would be lost. On resale/recycling of baby items this meant that second hand users/purchasers were unlikely to see the warning.