Coroner warns on sharing hospital beds after baby dies

A coroner wants medical authorities to change their attitudes about newborn babies sharing a hospital bed with their mothers after the death of a Nelson baby.

Sophie Linda Parker died within a day of her birth at Nelson Hospital on July 31, 2006, due to a combination of a nose defect and bedsharing, a pathologist found.

Sophie had been unsettled and was left to breastfeed with her exhausted mother. A midwife did not move Sophie to her cot as promised once she was asleep.

Coroner Ian Smith said the circumstances should have signalled to staff that bedsharing should not take place. He found Sophie died from accidental asphyxia.

He wants the Health Ministry and Nelson Marlborough District Health Board to favour a policy of no bedsharing except when mothers are breastfeeding.

Pathologist Jane Zuccollo said that, if Sophie had fallen off her mother’s breast, that could have compromised her or possibly caused death.

Sophie was born with a significant depression on the bridge of her nose. Difficulties with her airway, combined with the bedsharing, had led to her death.

The nose shape and an overly tired mother was a high-risk combination for bedsharing, Dr Zuccollo said.

Mr Smith said Nelson Marlborough District Health Board had not gone far enough in changing bedsharing guidelines after Sophie’s death.

Staff should err on the side of not having babies in bed with their mothers, point out all the dangers, and should consider bedsharing only after a robust discussion with mothers who wanted their babies in bed with them, he said.

A record should be kept of discussions with expectant mothers about bedsharing.

At the time of Sophie’s death, the board’s bedsharing policy was to consider it if the mother wanted it, if babies wanted to breastfeed frequently or were unsettled. Sophie fell into the last two categories.

Mr Smith was told that midwives caring for Mrs Parker and Sophie thought that bedsharing was quite common in hospitals.

Midwife staff should have recognised Mrs Parker was extremely tired, Mr Smith said. She agreed to having Sophie in bed with her on condition the baby would be put in a cot when she was settled.

However, midwife Mary Cowan decided against moving Sophie because she did not want to disturb baby and mother, who were both sleeping.

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