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Open verdict in death of baby found not breathing on mattress, coroner flags safe sleeping practices

Open verdict in death of baby found not breathing on mattress, coroner flags safe sleeping practices

File photo of an infant (Photo: Jeremy Long)

SINGAPORE: A coroner has declared an open verdict in the death of a two-month-old baby who was found face down and not breathing on his mattress, flagging safe sleeping practices to parents and caregivers.

The boy was two months and three weeks old when he was found unresponsive by the family's domestic helper in a Sengkang flat and was later pronounced dead in hospital on May 17 last year.

In findings made available this week, State Coroner Kamala Ponnampalam declared the open verdict after a thorough investigation, including an autopsy examination, failed to ascertain the cause of death. Suffocation was not ruled out.

The coroner flagged unsafe sleeping practices that possibly led to the death. At about 7pm on May 17 last year, the family's domestic helper had bottle fed the baby about 130ml of breast milk before burping him and waiting for him to fall asleep.

She then placed him down on a mattress in a prone position, with his head turned to the right, and left the bedroom.

She spent about an hour after this doing the dishes, helping the family's two daughters with their showers, before taking a shower herself and doing the laundry.

After about an hour, the maid wondered why the baby had not cried and went to check on him. She found the infant face down on the mattress and lifted him up to see that he was not breathing and that his face was pale.

The maid rushed out of the room carrying the baby and called his mother, asking her to come home right away because the baby was not breathing.

The baby's father arrived home soon after and found the maid crying with the baby in her hands. He saw that his child was not breathing and had milk dripping from his nose, and immediately took him to hospital.

However, the baby continued to be unresponsive and pulseless despite emergency aid, and he was pronounced dead at 9.51pm.

An autopsy found no obvious, significant abnormalities, with the forensic pathologist saying that a prone sleeping position is not likely to cause or contribute to death, if there was no evidence of co-sleeping, or scene evidence indicating that the baby's nose or mouth was covered.

He added that if the baby was face down with his external airways obstructed, it is possible that this could lead to suffocation and death.

However, such obstructions usually lead to autopsy findings such as injuries or abrasions around the nose and mouth, but these were absent from this case, said the pathologist.

"Based on the evidence led, there is no basis to suspect foul play," said the coroner. "Following a thorough investigation, including autopsy examination with ancillary testing, a review of the circumstances of the death, and (the baby's) clinical history, his cause of death remains unascertained. I am therefore constrained to record an open verdict."

She added that suffocation cannot be determined or excluded with certainty in this case.


The baby's parents raised several concerns during the coroner's inquiry. They asked why the maid had placed their child to sleep on a mattress in his sisters' bedroom instead of in his baby cot, and why she had fed him breast milk instead of formula milk in the evening, as was the routine.

The maid testified that she had placed the boy in his sisters' bedroom as it was nearer to the kitchen and living room, where she could hear him if he cried.

They also asked why the maid had checked on the baby only once and after almost an hour, questioning if she was distracted by her phone. The maid had testified that she did not use her phone in the hour before finding the unresponsive baby.

They were of the view that the maid had been neglectful in looking after the baby, and said this neglect had caused or contributed to his death.

The maid testified during the inquiry that she was not distracted at the time of the incident, nor preoccupied with financial issues.


The coroner reminded parents and caregivers of the importance of safe sleep, pointing out that this case raises "unsafe sleeping practices which have possibly led to infant death".

"A baby who is placed to sleep on his tummy may become trapped in a face down position," she said. "Paediatricians and those involved in infantcare regularly emphasise the importance of (a) baby sleeping on its back."

She flagged the ABCs of safe sleep: Alone, Back, and Crib. A baby should not sleep in the same bed as others but not necessarily in a different room; a baby should be put to sleep on its back, and in a well-built crib that is free of loose bedding, pillows and toys.

"These are steps which parents can adopt to ensure that their baby sleeps safely. Caregivers must be advised of the arrangements as well to ensure a safe sleeping environment for the infant," she said.

She conveyed her condolences to the baby's family for their tragic loss.

Source: CNA/ll(mi)


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