A coroner has raised concerns after a ‘dog-tired’ first-time mother was advised by midwives to breastfeed her newborn baby lying down in bed, leading to the baby tragically choking to death.
Bolton assistant coroner, John Pollard, has rubbished the advice given to a new mum after her baby choked to death in August last year.
During the inquest into baby Louie Bradley’s sudden death, more details came out that the baby’s mother, Ann, had been taught a feeding technique that went against national advice and Nursing and Midwifery Council (NMC) guidelines.
Ann Bradley, a teacher from Harwood, Lancashire, had just given birth to her first child only a day earlier. After having difficulties with breastfeeding, her midwife taught her a technique that involved lying side-by-side in bed with the baby.
‘They said we could lay on our sides,’ Ann said.
However, after falling asleep from sheer exhaustion, Ann woke up to find her baby white and lifeless.
Unable to revive her baby, the hearing was told that baby Louie had died from various factors, including an accidental obstruction of the airways. The baby also had undiagnosed bronchopneumonia and symptoms of a common cold.
The coroner said that the technique to help mothers struggling to breastfeed went against national advice to avoid co-sleeping because mums are likely to be very tired after giving birth and are therefore at a greater risk of falling asleep naturally.
He added that is was ‘extraordinary’ that a new mum was left alone with her baby when she was ‘dog tired’ after a long labour.
He has also written to Bolton NHS Foundation Trust raising concerns about breastfeeding advice given by midwives and healthcare assistants.
Concerns were also raised about the absence of some details from standard medical records with ward staff criticised for not completing documents and failing to record ‘significant’ details adequately. This totally goes against the rigorous training and supervision which midwives go through.
‘Scrutiny for Midwives ‘
Ann told the court she was never told not to lie in bed while feeding.
The midwife who taught her the technique, Jane Westhead, said that sharing a bed is discouraged after bed safety awareness is discussed.
‘We make them aware of the dangers. I don’t know if there’s an actual policy, but that’s what we do.’
Jane, who worked at Royal Bolton Hospital for nine years at the time of the incident, referred to specific guidelines about bed sharing in her evidence but the coroner said that advice given had been contradictory.
The coroner also expressed concerns that breastfeeding in bed with the curtains closed, meaning that medical professionals couldn’t see if any problems occurred, would sometimes happen.
But midwife Jane said it happens because women don’t want people walking past while they’re breastfeeding. ON a full ward or even in a smaller room of maybe 4 or 6 women it is often seen that all the curtains are closed around the women – either as a seclusion to cover them as they have their quiet moments with their babies and or their visitors. More so when they are trying to breastfeed and settle their baby.
‘Such a tragedy’
Following the inquest Val Clare, Head of Midwifery at Bolton NHS Foundation Trust, said:
‘It is such a tragedy when the unexpected death of a baby takes place. This was a very rare event and we feel for Louie’s family.
‘We are a Level Three UNICEF baby friendly initiative accredited unit which is the highest standard for breastfeeding and is a prestigious award, however, we always strive for improvement and so, taking into account the coroner’s comments, will review guidance.’
Breastfeeding when you’re tired
The Lullaby Trust, a UK charity that aims to reduce the number of SIDS deaths and support bereaved families, issues the following advice regarding breastfeeding in bed or lying down:
‘Breastfeeding reduces the chance of SIDS, so we would always try and help you work out a way to continue breastfeeding in the safest way possible.
If you feel you might fall asleep because you are lying down, it might be worth trying to feed in a sitting position or step outside of bed to breastfeed.
‘Make sure you know the advice on when never to bed share so you know when to take particular care. However, it is really important that you do not accidentally fall asleep with your baby on a sofa. If you think you might fall asleep, put the baby down in a safe place to sleep.
‘If you are breastfeeding, have your partner stay up with you, breastfeed in a different position where you are confident you might not fall asleep or feed the baby somewhere else.’
The Lullaby Trust also says to never bed share with your baby when you’re particularly overtired as this can increase the chance of SIDS.
Maybe it is time to discourage this practice, how are midwives supposed to see through a closed curtain and keep an eye on what is going on behind them. This is such a tragedy and a new baby not surviving past a few hours.
Midwives on the whole work hard and are in such a trusted position, and Royal Bolton Hospital will need to relook at their policies and procedures so that no more babies are lost due to not being fully supervised whilst in hospital.