Multiple fractures detected after baby's sudden death

A four-month-old baby who stopped breathing after being laid face down on top of a quilt on his sister's bed was discovered to have suffered multiple fractures to his knees and ankles following his death. Although it did not cause or contribute to his death, they were deemed to not be accidental, with some of the injuries occurring shortly before he passed away, an inquest has heard.

The baby boy, who was born and lived in Plymouth, passed away at Bristol Children’s Hospital on May 19, 2018, three days after being hospitalised. The inquest heard he would go to settle more quickly in his sister's bed, but 'generally' slept in his cot.

It was reported by his mother that the father would 'bicycle' the baby's legs to wind him and as he moved a lot during feeding, and that he would also 'trap' his legs between his own legs to stop him from kicking out. There was a suggestion made by the mother that he would get 'stressed' when he didn't feed, and there was a prior occasion when she felt he had put the baby down onto the bed 'too forcefully'.

The inquest at Exeter Coroner’s Court today, November 26, heard the baby was born prematurely in Plymouth at 32 weeks and remained in hospital for more than two weeks, following initial intensive care,

He was discharged on January 19 with a sleep apnea monitor which tells parents every time a child takes a breath and when no breathing is detected for 20 seconds an alarm sounds. However, he was readmitted again the following day after becoming very unwell and was diagnosed with meningitis.

He was discharged on February 4, under the care of the neonatal intensive care outreach team. On February 23, a padetriatic community nurse visited the family at home. In a statement, she recalled raising concerns about the baby's sleeping arrangements which included letting the baby cry itself to sleep downstairs.

She advised the mother he should sleep in the same room as them for the first six months and said to stop putting cushions in his crib to stop him rolling stating it was dangerous as it increased the risk of smothering. The mother, who was described as showing 'good emotional warmth', was provided with safe sleeping advice which included laying the baby on his back and monitoring his weight.

The baby's GP told in a statement that both parents attended the surgery in March for his six to eight week check up. He was said to be developing well and no concerns were raised by the parents.

On April 5, a home visit was made by a health visitor and the padetriatic community nurse. The baby was said to be more settled at night but the professionals noticed an 'unusual startle and flicker' which had also been noted in a padetriatic review that he was 'generally jittery'.

His parents were advised to monitor any unusual movements and they returned the sleep apnea monitor stating it was making them more anxious. It was noted by a health visitor on May 9 the baby had not gained weight in the last two weeks so plans were made for regular weigh-ins, but no concerns were raised.

In interviews with police, the mother said she took care of the baby's daily care and said the day before the incident he had been snuffly with a cold and chesty and had been sick on two occasions which she thought was due to him drinking too much of his bottle.

On May 16, she recalled he had woken up as normal at around 7.10am in his cot on his belly. She said she left him at home with his father while she picked up their older daughter from school.

She recalled he was laughing and awake until 4.30pm when his father took him to his sister's bed. She said she checked on him at 5.15pm and said he was fine on his tummy with his head turned to one side but seemed hot so she took his blankets off which she had been using as the heating was not working.

She stated he was on top of a quilt and she left him to make his bottle, but when she returned 10 minutes later he was not responsive

She said: "He was lying face down on the quilt. I could see sick around his mouth but not on the bed."

After screaming for help, his father took him downstairs to carry out CPR. An ambulance was called and he was taken to Derriford Hospital and then Bristol.

She recalled they had planned to follow their baby to Bristol but instead went home. They were awoken the next morning by police knocking on their door. She said she initially didn't answer because she 'feared' her baby had died, but eventually did.

The mother recalled: "[My partner] struggled to leave Plymouth because of his agoraphobia." She added: "I was torn between them both needing me."

When initially questioned about their baby's death, she admitted misleading health officials and police by telling them their baby had been placed in his cot instead of his sister's bed by his father.

She said: "I knew he should not have been on the bed and I thought I would have my children taken away so we decided to say he was in his cot."

When the father was interviewed by police, he recalled his son was not an easy baby to feed because he would kick his arms and legs out and scream.

He said he would 'stretch his legs out and press on his knees', claiming he had seen a paediatrician do it.

He said he would sometimes put his son on his stomach to settle him, which he had seen done in the neonatal intensive care unit, and both he and his partner had decided to sometimes let him sleep on his sister's bed because he 'hated' the mattress in his cot. He added the siblings never slept in the same bed together.

An extensive post-mortem examination was carried out by home office forensic pathologist Dr Amanda Jeffery with input from specialist experts. She concluded there was no evidence of trauma to the brain, a neurological problem, or new or old bruising to the body. However, healing changes were detected on both sides of the brain.

Dr Jeffery said it was not possible to say if it was caused by a previous trauma - such as an impact or shaking injury - or from previously having had meningitis. Multiple 'non-accidental' fractures of varying ages were detected on the baby's knee and ankle joints which suggested being caused by a 'pulling or twisting' of the limbs.

The 'bulk' of the fractures were dated up to six days before his death. The others were said to have occured seven to 14 days prior, and three to five weeks before death. They were said to have indicated 'at least' three episodes of trauma.

Dr Jeffery said: "Gentle careful handling of a child would not result in such fractures."

She added: "The most recent fractures could have occurred around the time of medical collapse but could pre-date it by a day or two."

She continued: "The unusual actions of [his dad] could conceivably cause these injuries if the handling and movement was particularly rough or careless."

It was also noted that the fractures meant it was not possible to exclude non-accidental injury to the limbs and that the cause of his respiratory arrest remains 'unascertained'.

Giving her conclusion, Dr Jeffery stated potential causes for the baby's cardiac arrest included sudden infant death due to an unexplained medical event, aspiration of stomach contents, the sleeping position, the airway being compromised by soft bedding and a non-accidental cause.

She said: "The difficulty in this case is we simply don't know what caused that cardiorespiratory arrest. There remains multiple potential causes of it, both natural or unexplained, or potentially relating to an unsafe sleeping environment.

"The additional findings cast doubt and cause concern that we may have a non-accidental death that we simply have not been able to determine a definitive cause."

Due to those uncertainties, the medical cause of death given was hypoxic ischemic brain injury with bronchopneumonia caused by an out of hospital cardiac respiratory arrest of 'unknown cause'.

Police confirmed that following a thorough and lengthy investigation into the baby's death, no evidence of suspicious circumstances surrounding his death were found.

Recording an open conclusion, senior coroner Philip Spinney said: "Despite a comprehensive post-mortem examination, the probable cause of the cardio respiratory arrest cannot be determined."