Ezra Boulton
1 Jul 2019 · Coroner Samantha Marsh · Portsmouth and South East Hampshire
The coroner's concerns
1. lack of continuity of antenatal care
“throughout her pregnancy (this being her first pregnancy) ([the deceased]'s mother) did not see the same midwife twice”
2. infant deaths due to co-sleeping
“making safe sleeping information readily available to all parents at an early stage may significantly reduce the risk of future infant deaths due to co-sleeping”
3. automatic criminal offence of overlay
“midwives are unaware that causing the death of an infant due to co-sleeping becomes an automatic criminal offence of”