• An infant was found not breathing when his mother came to check on him and their confinement nanny
• The nanny had cradled him in her arms, then fallen asleep with his face against her chest
• A coroner recorded an open verdict because experts could not definitively determine how the baby died
• Nevertheless, the coroner reiterated her warning that infants should always sleep on their backs and not in a prone position

SINGAPORE — A coroner on Thursday (Oct 28) ruled that the cause of death for a three-week-old baby boy could not be ascertained, after he fell asleep in the arms of his confinement nanny who had also nodded off.

In her written coroner’s inquiry findings, Coroner Kamala Ponnampalam reiterated her warning to parents and caregivers that infants who fall asleep in a prone position are “more likely to fall victim to accidental suffocation”.

“We are once again confronted with a case involving poor sleep practices, which may have led to infant death,” she said, noting that paediatricians regularly emphasise the importance of babies sleeping on their back.

Nevertheless, because experts could not determine if the baby had died from suffocation or sudden infant death syndrome, among other possible causes, the coroner was constrained to record an open verdict.

The evidence did not suggest foul play as well, Coroner Ponnampalam said.

The intent of a coroner's inquiry is not to apportion blame but to determine why and how a death happened.

BABY WAS RELATIVELY HEALTHY

The baby was born healthy in late October last year, the coroner’s findings showed. His parents engaged a confinement nanny, Madam Sien Yem Leng, to care for him.

The 57-year-old occupied and slept in the same room as the baby, who was both bottle-fed and breastfed at intervals of two to three hours. He was relatively healthy aside from developing a hoarse voice from gastroesophageal reflux.

The baby’s mother had placed a portable camera inside the bedroom to monitor her son and Mdm Sien was aware of this.

On Nov 19 last year, after Mdm Sien bottle-fed the infant, he made sounds of discomfort.

The nanny then carried him several times in different positions to get him to fall asleep, before sitting on her bed and leaning against the wall behind her with the baby in her arms.

The mother gave evidence that she last checked on the pair at about 11pm. She then woke up herself at about 4am, realising she had overslept as she wanted to pump breast milk at 3am.

Upon seeing that the breast pump accessories were unwashed, she went to the baby’s room at about 4.15am to remind Mdm Sien to do it.

She found both of them asleep, with the baby’s face against the nanny’s chest. Mdm Sien was startled and woke up when told to do the washing.

The nanny had earlier placed a piece of yellow cloth between herself and the baby. The cloth acted as a barrier for hygiene purposes when she carried him.

The boy’s mother said that she saw the cloth on his face when Mdm Sien carried him to the cot. Mdm Sien then removed it before leaving to wash the breast pump accessories.

However, the boy’s mother then checked on him and found him unresponsive, with the left side of his face appearing darker. She took him out of the cot and placed him on the nanny’s bed, calling out “wake up, baby", but received no response.

Mdm Sien returned and the mother questioned her about the darker tone on his face, but she could not give an explanation.

After the mother alerted her husband, they took the baby to KK Women’s and Children’s Hospital. Doctors found that he was pulseless with no sign of life.

Resuscitation attempts proved futile and the baby was pronounced dead at about 5.20am.

BASICS OF SAFE SLEEP

Dr Teo Eng Swee, a senior consultant forensic pathologist from the Health Sciences Authority, conducted an autopsy on the baby and found that sudden infant death syndrome and asphyxia could not be ruled out, but that his cause of death was “unascertained”.

He added that there was no evidence the baby had inhaled milk that may have caused him to choke.

He noted that based on Mdm Sien’s account, there was also no obvious information that the baby’s face was facing or buried in the nanny’s chest or shoulder area.

The boy’s mother told the coroner’s court that she had previously told Mdm Sien not to carry the baby on her chest for prolonged periods due to suffocation, and not to put him in an inclined position after feeding due to his acid reflux problem.

She further stated that Mdm Sien, who came well-recommended by a friend, appeared to ignore her concerns because she was an experienced nanny.

She had no formal training and worked for nearly 20 years as a confinement nanny, gaining experience by caring for her younger siblings and from her previous job where she worked with children.

Mdm Sien said that on that fateful morning, she did fall asleep while carrying the baby but she claimed that she did not sleep soundly as he kept moving.

She alternated between two carrying positions and checked the baby periodically.

She added that she had wanted to put the baby in his cot after carrying her for a while, but he kept moving and fretting. She then held him in an inclined position against her shoulder, waiting for him to sleep more soundly, before she dozed off.

Coroner Ponnampalam wrote in her findings: “Parents and caregivers must bear in mind that fatigue can set in as they care for the infant through the night. It is best not to cradle the infant in the arms for long periods of time and risk the baby falling asleep in an unsafe sleep position when the caregiver dozes off even briefly.

“In cases where the baby is unable to settle, caregivers must adopt other strategies or hand over to another adult than risk the baby falling asleep prone.”

She also listed the ABCs of safe sleep — Alone (the infant should not sleep in the same bed as others), Back (the infant should always be put to sleep on their back), and Crib (a well-built one free of loose bedding, pillows and toys).

She gave her condolences to the baby’s family for their “tragic loss”.