AN INFANT died under his mother’s arm as they slept on a sofa after she was not warned about the dangers of co-sleeping, a coroner has said.
Two-month-old Ezra Boulton died in hospital after his father tried to wake him for a feed at around 1am and found him ‘lifeless’.
An inquest heard the baby’s mother was sleeping with the child having been ‘consuming alcohol throughout the day’.
The boy’s family ‘did not recall being given any information directly on safe sleeping’ from a midwife or health visitor but said a leaflet with information was given ‘almost as an after-thought,’ a coroner said.
An inquest into the infant’s death heard paramedics attempted CPR at the family’s Portsmouth home but then the boy was rushed to A&E at Queen Alexandra Hospital in Cosham.
‘Despite the full range of medical interventions and resuscitation attempts being given it became apparent that his presentation was incompatible with life and further resuscitation attempts would be futile,’ coroner Samantha Marsh said.
‘Ezra was pronounced dead at 2.05am.
‘On the balance of probabilities the suboptimal sleeping position on the sofa, which may have been influenced by alcohol consumption, and the missed opportunities to remove him to a safe sleeping environment caused or contributed to his death.’
Ms Marsh has written a preventing future deaths report questioning why Ezra’s mother did not see the same midwife ahead of the uneventful birth, and suggesting there was a ‘serious risk of future death posed by this lack of continuity of care’.
Responding to the report, Portsmouth Hospital NHS Trust chief executive Mark Cubbon by March next year 35 per cent of mothers would have a ‘continuity of carer pathway’ - meaning having the same midwife through pregnancy, birth and postnatal care.
The family said it did not receive a visit from a health visitor for seven weeks. Solent NHS Trust provides city health visitors and was approached for comment.
Mr Cubbon told coroner Ms Marsh ‘the issues you have raised are already priorities for the trust’.
Dr John Knighton, medical director at Portsmouth Hospitals NHS Trust, said: ‘I would like to offer my condolences to baby Ezra’s family on behalf of the trust. The death of any child is desperately sad, and shocking, for everyone involved.’
At the inquest in June, Ms Marsh, who raised four issues in her report, said the sleeping position, alcohol consumption, and missed chances to put the baby in a ‘safe sleeping environment’ had ‘caused or contributed to his death’.