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Grace Joy Roseman died at seven weeks when she manoeuvred herself over the edge of her £300 luxury cot and a ridge cut off oxygen supply to her brain.
Grace Joy Roseman died at seven weeks when she managed to manoeuvre herself over the edge of her £300 luxury cot at the family home in Haywards Heath, and a 'safety' ridge cut off oxygen supply to her brain.
West Sussex coroner Penelope Schofield has issued a report expressing concern over the Bednest Bed Side crib - which is endorsed by the National Children's Trust.
Ms Schofield said: "In my opinion there is a risk that future deaths will occur unless action is taken."
The coroner's report says Grace was placed in her cot by her mother at around 8:30am on April 9.
The cot has a moveable panel on one side, which can be folded down - leaving the depth of the cot just seven centimetres high.
Her mother, Esther Roseman returned about 90 minutes later to find Grace lying with her head over the edge of the crib, with a bruise on the side of her neck.
The provisional cause of death was given as asphyxia, caused by Grace managing to get her head over the slender edge of the cot, which then cut off her windpipe and oxygen supply.
1. The Manufacturer’s website clearly shows pictures of babies in these cots with the sides in the incompletely lowered position.
2. The manufacturer’s instructions for this cot indicate that a baby should not be left unattended other than when both sides of the bednest are up and secure. In addition any tilt applied to the cot should be restricted to less than 5cm. However this is of little assistance to anyone who has been given a second-hand cot without these instructions being readily available. There are no warnings on the cot itself.
3. Should another baby be placed in the prone position and left with the side incompletely lowered again in one of these cots, another death could occur.
4. If the cot side is not safe to be incompletely lowered or for the cot to be tilted more than 5cm then it should be questioned as to whether these should be options available at all.
5. These cots are currently available to be purchased through the manufacturer, NCT and other leading stores.
6. There are a large number of second-hand cots being marketed for sale.
She also pointed out that some safety warnings are printed on a paper instruction but not on the crib itself.
The report calls for urgent action to be taken to prevent further deaths and says the investigation into the death has not been concluded and an inquest has not yet been held.
The West Sussex Coroner has informed us of the tragic death of Grace Roseman two weeks ago. We are greatly saddened and extend our heartfelt condolences to Grace's parents and family.
We are doubly upset to hear this news, since the concept behind Bednest's design is first and foremost about baby health and safety and came originally from highly experienced neo-natal nurses.
Recent press articles have incorrectly stated that the coroner has called the cot 'dangerous' and asked for it to be withdrawn from sale. This is not the case. The coroner has highlighted that all safety guidelines for the correct use of the crib are laid out in the instruction manual, but due to a growing second-hand market for our Bednest cribs, these instructions manuals may not be passed on. This may be, sadly, what happened with Grace's crib.
We advise all parents acquiring a second hand crib to first of all visit our website FAQ where they will find out how to obtain the full instruction manual for use with their Bednest. These instructions and warnings include:
-Do not leave the baby unattended if the crib sides are not both up and secured
-Do not tilt the crib by more than 5cm.
Following this incident we are now considering displaying these basic instructions on the side of the crib itself and not just in the instruction manual. We are also fully cooperating with the Coroner's investigation, as well as independently looking at other ways of ensuring the safety of our cribs, especially for the second hand market.
We are confident of the design and safety of the Bednest, which has passed the latest rigorous UK and USA safety standards and which has been used by thousands of parents over the last four years. As with any baby product, we highlight safety hazards in our manual. We also endorse expert advice on safe sleep including sleeping positions.
Bednest customers can safely use the product in accordance with its instructions and we will send a replacement instruction manual to anyone who requests one. We constantly review our procedures as part of our ongoing commitment to ensuring that parents are fully aware of the correct and safe way to use the product.
We would always strongly recommend all parents who acquire any second-hand cot (or any second-hand baby product) without an instruction manual, to contact the manufacturer for a replacement copy before using the product.