Baby died after exhausted mum sent home just four hours after birth

A newborn baby sadly died after her exhausted mum was sent home just hours after a long birth, an inquest has found. Baby Evelyn was just one day old when her ‘exhausted’ mum fell asleep while trying to breastfeed her in her own bed.

The Coroner’s report states that Evelyn was born at Leeds General Infirmary on Tuesday, September 26, 2023 at 4.38am, following a prolonged labour. She and her parents were discharged home four afters after the birth - despite her mother being “exhausted”, having had little sleep from Sunday, September 24, until her baby was born.

At around 1.45am on Wednesday, September 27, the baby was brought into her mother’s bed because she was unsettled. As she was being breastfed the mother is thought to have fallen asleep. When she woke up again at around 4am the baby was under the mother’s breast, in an unresponsive condition.

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Despite emergency treatment she could not be revived and was sadly pronounced dead at 7.50am at Leeds General Infirmary - the same place she had been born just a day earlier.

Evelyn’s cause of death was recorded as “unascertained”, however the coroner said it is likely the death was caused by the accidental suffocation of the baby by a sleeping adult.

Senior coroner, Kevin McLoughlin, believes that Evelyn’s death could have been prevented had her mother not been sent home so soon after the birth. Mr McLoughlin added that they believe there is a risk that future deaths will occur unless the hospital takes action.

In a report, which has been sent to Leeds Teaching Hospitals NHS Trust, the coroner listed the following matters of concern:

• The Mother endured a prolonged labour and had little sleep from Sunday, September 24, until her baby was born at 4.38am on Tuesday, September 26. She was exhausted.

• The baby and her parents were discharged home 4 hours after the birth - at 8.39am.

• The death of the baby is probably due to the exhausted mother falling asleep whilst trying to breastfeed the unsettled baby in her own bed sometime after 1.45am on Wednesday, September 27.

• Consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and induced delivery. Had she been permitted to sleep in hospital for a few hours knowing that her baby was being monitored, the tragedy may have been avoided.

The coroner added that action should be taken by the hospital. Mr McLoughlin added: “In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.”

Leeds Teaching Hospitals NHS Trust has been given 56 days to respond to the report with details of action taken or proposed to be taken.

In a statement Rabina Tindale, Chief Nurse, Leeds Teaching Hospitals NHS Trust, said: "We send our heartfelt condolences to Evelyn’s family at this incredibly difficult time and what happened to them is truly tragic.

"All our mums and babies are individually assessed before they are discharged home and safer sleep advice is provided antenatally and again before discharge.

"Previous independent reports into Evelyn’s death made no safety recommendations for the Trust and we will respond fully to the Coroner’s report."

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