Open verdict on 2-month-old baby's death, safe sleeping practices important: Coroner

Open verdict on 2-month-old baby's death, safe sleeping practices important: Coroner
The baby was found face down and not breathing on his mattress when he was found unresponsive by the family's domestic helper.
PHOTO: Unsplash

Following the death of a two-month-old baby who was found face down and not breathing on his mattress, a coroner has declared an open verdict in his death and seeks to remind parents and caregivers of the importance of safe sleeping practices.

This comes after a thorough investigation — which included an autopsy examination — failed to establish the cause of death.

According to State Coroner Kamala Ponnampalam in findings made available this week, suffocation cannot be determined or excluded with certainty in this case.

However, she pointed out that the case raises “unsafe sleeping practices which have possibly led to infant death”.

According to reports, the baby was two months and three weeks old when he was found unresponsive by the family’s domestic helper in a Sengkang flat.

Here is the sequence of events that led up to the boy’s death:

  • The domestic helper bottle fed the baby breast milk (about 130ml) around 7pm on 17 May 2019. She then burped him and waited for him to fall asleep.
  • Baby was placed down on a mattress in a prone position where he lies flat with the chest down and the back up. His head was turned to the right.
  • Helper proceeded to leave the bedroom to do the household chores and helped the family’s two daughters with their showers.
  • She also took a shower herself and proceeded with doing the laundry.
  • About an hour later, the helper noticed that the baby had not cried and went to check on him.
  • The infant was found face down on the mattress. She lifted him up and realised he was not breathing and that his face was pale.
  • The helper rushed out of the room with the baby and called his mother to return home immediately.
  • Baby’s father arrived home soon after and found the helper crying with the baby in her arms.
  • The little one was not breathing then and milk dripped from his nose.
  • He was immediately brought to the hospital by his father.
  • The baby was said to remain unresponsive and pulseless despite emergency aid.
  • He was later pronounced dead in the hospital on May 17, 2019 at 9.51 pm.

No basis to suspect foul play, coroner says

Autopsy results revealed that no obvious, significant abnormalities were found in the baby, in light of how he was placed in a prone sleeping position.

According to the forensic pathologist, a prone sleeping position is not likely to cause or contribute to death if the following are not present: evidence of co-sleeping, or scene evidence indicating that the baby’s nose or mouth was covered.

In the event the baby was placed face down with his external airways obstructed, the pathologist said that suffocation and death could be possible as a result.

However, in this case, there were no such obstructions as autopsy findings did not reveal any injuries or abrasions around the nose and mouth, he added.

Hence from the evidence gathered, the coroner stated that there is “no basis to suspect foul play”. 


According to reports, the baby’s parents were of the view that their domestic helper had been neglectful in looking after their child which eventually led to his death.

One of the concerns the parents raised during the coroner’s inquiry was over why the baby was placed to sleep on a mattress in his sisters’ bedroom instead of in his baby cot, to which the helper testified that it allowed her to hear the baby if he cried as it was nearer to the kitchen and living room. 

The parents also questioned why the helper had fed their son breast milk instead of formula milk in the evening — a shift from the usual routine.

They also questioned the helper if she had been distracted by her phone such that she only checked in on the baby only once after almost an hour. She testified that she did not use her phone in the hour before noticing that the baby was unresponsive.

Coroner highlights safe sleeping practices

As a rule of thumb, paediatricians and those involved in infant care often emphasise the importance of placing a baby to sleep on his/her back, according to the coroner.

She identified the ABCs of safe sleep –

  • Alone – A baby should not sleep in the same bed as others although not necessarily in a different room
  • Back – A baby should be placed on his/her back to sleep
  • Crib – A baby should be placed on his/her back to sleep, and in a well-built crib that is free of loose bedding, pillows and toys

She highlighted that parents can adopt these steps to ensure safe sleep for their infant. In addition, she says that caregivers must be advised of the arrangements as well to ensure a safe sleeping environment for the infant. 

This article was first published in theAsianparent.

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