The death of a baby whose head got stuck between a foam mattress and a portable cot side has prompted a public safety caution.
Coroner Christopher Devonport said the death of "Baby D" in Nelson in December 2014 "highlights the importance of ensuring that the possibilities of accidental asphyxia are eliminated, including that baby sleeps on a thin, firm mattress".
The baby, who was 10 months old, had been placed in a portacot by her mother. Her father found her limp and unresponsive about an hour later, and she was pronounced dead at Nelson Hospital an hour later.
Devonport said Baby D's grandmother had bought the portacot secondhand two months earlier. She had decided it needed a more substantial mattress and had added a foam layer, placing a mattress protector and sheet over it.
The foam mattress was described as being between 10 and 20cm thick by different family members. It was longer than the cot-supplied mattress and folded up in curve at the end.
The baby's mother stated that she had wrapped her loosely, "not like a newborn so her arms couldn't flail around", and placed her on her back without a blanket.
Baby D was out of the wrap when found by her father, with her face against the thick mattress and wedged between the portacot wall and the mattress.
A pathologist determined the cause of death as accidental asphyxia, with no evidence of injury or disease.
Devonport said the baby's death appeared to be the result of getting wedged between the soft mesh side of the portacot, and the thicker mattress.
"It is important that babies/infants are put to sleep face up, face clear," he stated.
This had been done, but Baby D appeared to have removed the loose-fitting wrap and rolled between the soft mesh and the thick mattress, Devonport said.
He found the cause of death was accidental asphyxiation and ruled that neither the baby nor her family could be identified in any publication.
Safe portacot/portable cot use
You can download a brochure about safe portacot use from the Kidsafe NSW site. Here are some guidelines to follow.
- Always follow the manufacturer's safety instructions for assembling and using the portable cot.
- Make sure the sides are fully clicked into place and the locking device is secure.
- Check for tears in the mesh or fabrics. Repair any tears immediately.
- Regularly check the cot frame for cracks.
- Use the cot mattress provided with the portable cot.
- Always make sure the mattress and bedding fits snugly at the sides and the ends - a gap no more than your index finger
- Do not put an additional mattress in the cot. Small children can become wedged between the mattresses and suffocate.
- Do not use pillows or bumpers. Children can become wedged in a pillow or bumper and suffocate.
- Discontinue using the cot before the child is able to release the locking devices possibly causing the portable cot to collapse.
- Do not use a portable cot if your child weighs more than the recommended weight advised by the manufacturer.
- Don't allow older children to climb in and out of the portable cot as this may cause strain to the framework.