Coroner to notify HSE of death of baby carried in sling

A coroner is to raise awareness with the Health Service Executive about the potential danger of baby slings following the death of a five-week-old baby boy due to sudden infant death syndrome (SIDS) in Dublin two years ago.

A pathologist told an inquest into the death of baby Ruadhán Bradshaw-Hall that there was a risk factor associated with the use of slings for babies and SIDS.

A sitting of Dublin District Coroner's Court heard the young boy was found unresponsive after he had been carried around in a sling by his mother as their family visited a Christmas market near their home in Garristown, Co Dublin, on 10 December 2022.

He died 11 days later at Children’s Health Ireland at Temple Street in Dublin. The inquest heard he died of severe brain injuries caused by a lack of oxygen.

The boy’s father, Keith Bradshaw, gave evidence of how he, his wife, Sinead; his two stepsons and the couple’s two children, had gone for a walk in Garristown.

Mr Bradshaw described how he had given his wife, who was carrying Ruadhán in a sling, his coat to put over her sleeveless jacket because of the "arctic" weather conditions on the day.

As they returned home briefly before going out to buy a Christmas tree, he claimed his wife came running in upset and screaming because there was something wrong with the baby.

Mr Bradshaw said his son had turned grey and had blood coming from his nose.

The inquest heard one of his stepson's provided CPR to the baby until paramedics arrived.

Mr Bradshaw recalled how he and his wife initially felt relieved after their son had survived the critical 48-72 hours and they had done "a little dance of relief" after doctors had told them he would be ok.

However, Mr Bradshaw said Ruadhán’s condition deteriorated over the following days.

He described the time his son was in hospital as "11 days of hell".

In a written statement, his wife, Sinead Hall, said she never had any sense there was anything wrong with her baby when he was in the sling until she got home.

Risk factor for babies in 'compromised sleeping position'

Mr Bradshaw also expressed concern that it had taken 27 minutes for an ambulance to arrive even though the nearest station was just 10 minutes’ drive away in Ashbourne, but crews from three stations further away had been used.

Pathologist Michael McDermott said the baby had suffered an acute single event prior to his death which he linked to the day he was found in an unresponsive state.

Dr McDermott concluded that the boy had died as a result of SIDS as a post-mortem had been unable to identify any other cause for his collapse.

While extremely unusual, he said SIDS deaths linked to slings were the subject of published reports which were the basis of a list of advice for their use known as "TICKS".

Dr McDermott said the adoption of the advice that the best sleeping position for babies was on their back in a cot in a room with their parents was the single biggest factor in a significant reduction in SIDS cases in recent years.

However, he warned that there was a risk factor for babies who were sleeping in a "compromised sleeping position" as it was known there was a higher incidence of SIDS with babies who were sleeping in a bed or in an armchair with their parents.

In relation to baby slings, Dr McDermott said the parent’s chest and clothing as well as the sling’s material itself and the baby’s own position could affect its breathing.

The pathologist said there was a "compromised sleeping position" in about half of all recent SIDS cases.

"There are some risks involved in the use of baby slings," he observed.

Dr McDermott stressed that Ruadhán’s parents should not blame themselves about what happened, after Mr Bradshaw said his wife was haunted by the fact that she had not noticed anything wrong.

"This is a tragic death. This is nobody’s fault. This is not something you did or failed to do," he added.

Asked about ambulance response times, Dr McDermott said someone could suffer significant brain injury after four minutes without oxygen.

Dr Gallagher said it was uncertain when the boy became unresponsive and there had only been "a very short window" before the situation could have become irreversible.

Mr Bradshaw said he was surprised to learn of the link between SIDS and slings and pointed out that he and his wife would have been "extra cautious" if they had such information at the time.

He expressed a wish that such information would be more prominent and publicly available for parents of newborns.

He said the couple felt that if just one variable had been removed from what happened that Ruadhán "would still be here".

The coroner recorded the cause of death as SIDS while being carried in a sling.

Dr Gallagher said she would return a narrative verdict to reflect the fact that the use of a sling was an additional risk factor but not a direct cause.

She also said she would notify the HSE about the case and ask for the relevant information about advice for new parents to be sent to all maternity hospitals, GPs and public health nurses.

Offering her condolences to Mr Bradshaw, the coroner said it was a very normal, natural thing for parents to want their baby close to them.

She added: "It wasn’t anybody’s fault. It was a very unfortunate and tragic death."

Dr Gallagher also praised the couple for how eloquently they spoke about how "a happy time had turned into an absolute nightmare."

At the conclusion of the inquest, Mr Bradshaw said there was not a day that goes by that they don’t think about Ruadhán.

He said their baby’s death had devastated their family and badly affected his wife’s mental health.

Mr Bradshaw said their two oldest children had been diagnosed with post-traumatic stress disorder and suffered nightmares and trauma.

"One of the most heartbreaking aspects of this is how very few resources there are in the State to help children come through bereavement," he added.

He expressed hope that something positive could result from their son’s death and informed the coroner that a charitable foundation had been set up in Ruadhán’s memory which had already raised €50,000.