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Coroner says there is a risk future deaths will occur unless action is taken

In a Corner Report to Prevent Future Deaths (Regulation 28) sent to BedNest Ltd, who are based in Stratford-upon-Avon and the National Childbirth Trust, the West Sussex coroner, Penelope Schofield, sets out her concerns following the death of Grace Roseman, a 7-week-old baby from Haywards Heath.

The coroner says that during the course of the investigation into the baby's death matters were revealed that give rise to concern. In her opinion there is a risk that future deaths will occur unless action is taken and that she had a statutory duty to report this to BedNest Ltd. The matters of concern were listed as follows:

  • The manufacturer's website clearly shows pictures of babies in these cots with the sides in the incompletely lowered position.
  • 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 cost should be restricted to less than 5cms. However this is of little assistance to anyone who has been given a second-hand cot without these instructions being readily available. There are now warning on the cot itself.
  • 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.
  • These cots are currently available to be purchased through the manufacture and other leading stores.
  • There are a large number of second-hand cots being marketed for sale.

The coroner then goes on to call for action to be taken.

In my opinion urgent action should be taken to prevent future deaths and I believe you have the power to take such action.

– Penelope Schofield, West Sussex Coroner

The coroner states that BedNest Ltd has 56 days to respond to her report. Tonight BedNest Ltd issued a statement saying:

We share the Coroner's concerns about anyone who has been given a second hand cot without instructions. However Bednest would like to point out that this information is available on the website and all cribs have safety stickers and a user guide with safety instructions with them when they leave the factory. It appears in this case, these were removed and not available

– BedNest Ltd

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Two people injured in police crash
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Cot warning after seven-week-old baby dies in Sussex

7-week-old Grace Roseman died in Bednest crib

A coroner has expressed concern over a bedside cot after a newborn baby from Haywards Heath was killed while she slept.

Seven-week-old Grace Roseman died while using a crib which could be joined onto her parents' bed.

She had manoeuvred herself over the edge of the Bednest - cutting off the supply of oxygen to her brain.

Grace Roseman was sleeping in a Bednest like this when she died. Credit: Bednest

‘We are greatly saddened and extend our heartfelt condolences to Grace’s parents.

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.

It is not the case that the coroner has called the cot “dangerous” and asked for it to be withdrawn.

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 instruction manuals may not be passed on. This may be, sadly, what happened with Grace’s crib.

We are now considering displaying basic instructions on the side of the crib itself.'

– Spokesperson for Bednest
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