SINGAPORE: A 19-day-old baby died from suffocation the first time he was placed on a bed beside a sleeping parent, a coroner found in documents released on Friday (Nov 29).

The baby's mother had placed him down on the bed next to her husband so that she could give her older child a bath. When she returned, the newborn had stopped breathing.



State Coroner Kamala Ponnampalam said in her findings that this case was "yet another unfortunate illustration of the increased risk of inadvertent suffocation resulting from co-sleeping with one's infant, for however brief a time".

"Parents need to be vigilant and observe safe sleeping habits at all times," she said, noting that KK Women's and Children's Hospital regularly advises parents not to co-sleep with their babies.

BABY'S FIRST TIME ON THE BED

The court heard that the baby's mother usually slept on a sofa in the living room of their Chai Chee flat with the newborn. Her husband slept in the master bedroom with their older child in a cot.



On the evening of Jun 8 last year, the baby's father told his wife to sleep with their older child instead, as he needed to do some work.

He worked through the night in the living room. When he went to sleep in the master bedroom the following morning at about 6.30am, the baby was still asleep in his playpen.

About half an hour later, his wife picked up the baby and placed him beside his father on the bed in the master bedroom.

This was the first time the baby had been placed on that bed.

His mother stated in the hearings that she had placed the baby on the bed because she did not want to leave him alone after he had been fed, as he was prone to spitting and vomiting.

She placed him on his back and cocoon-wrapped on the bed, before tapping her husband to tell him that baby was beside him and that he should watch out for him.

However, her husband later told the court that he was too tired and did not hear her.

When the baby's mother returned to the room at around 8.45am, she saw a pillow on top of the child, covering the upper half of his body. He also looked pale.

She woke her husband up, who carried the baby to the diaper changing room and realised that he was not breathing.

He started performing cardio-pulmonary resuscitation, and the baby was later taken to Changi General Hospital (CGH) by ambulance.

BABY WAS PLACED ON VENTILATOR

The baby was intubated at CGH and regained spontaneous circulation at about 9.45am.

He was then transferred to KKH, where he was assessed to be unresponsive with fixed and dilated pupils.

During his stay at KKH, there was neither movement nor spontaneous breaths while he was on the ventilator.

He was pronounced dead at about 2.30am on Jun 10.

A pathologist certified his cause of death as global hypoxia due to suffocation, with oxygen deprivation leading to circulatory collapse.

During the coroner's inquiry, a KKH quality service manager testified that the hospital conducts workshops to teach parents and caregivers about infant care.

Mothers are taught various techniques during hospitalisation including how to pick out signs and symptoms of a sick baby and how to respond.

A Child Safety Checklist given to parents upon discharge teaches parents that bolsters, pillows, blankets and plastic bags must be kept away from children to avoid unintentional suffocation.

They are advised to always position their baby on their backs, and reminded not to use a "sarong" cradle, and not to allow babies to sleep with them in the same bed, to prevent unintentional suffocation.

"The baby should sleep in a cot that meets safety standards," the court heard.

The coroner said she found no basis of foul play, and ruled the baby's death an unfortunate misadventure.

She extended her condolences to the family of the baby.