Bereaved parents Esther and Gideon Roseman say they are ‘very concerned’ that families can still easily buy a ’dangerous’ cot, 18 months after their baby died.
Coroner Penelope Schofield recorded a conclusion of ‘accidental death’ after a three-day inquest into the tragic death of Grace Roseman.
She found the baby had died after lifting her head over the lip of a foldable side of her Bednest cot, in April last year.
Unable to free her neck, Grace’s breathing was severely cut off and she died of asphyxia before being discovered by her horrified mother Esther, 39.
Ms Schofield said she was ‘very, very concerned’ about the number of cots still in circulation without vital safety modifications.
She criticised Bestnest for ‘lack of compassion’ and said there was ‘no evidence’ to support their suggestion that Grace’s sister Pearl, then a toddler of two, could have been involved in the death.
The inquest heard Esther describe the harrowing moment she discovered her daughter’s lifeless body at their Haywards Heath home.
Fighting back tears she said: “I found Grace with her head hanging over the side, facing upwards.
“Her head was on the side which was half-folded.”
“She was purple in colour. It was obvious she had been there some time - there was no sign of any life.
“I started screaming, ‘Grace is dead’.”
Esther and husband Gideon rushed Grace to the Princess Royal Hospital.
As many as 20 doctors fought for 20 minutes to resuscitate her but she was pronounced dead a few minutes later.
After Grace’s death, Trading Standards contacted Bednest, who presented two test certificates - one from FIRA (Furniture Industry Research Association) and one from the Swiss-based SGS - proving the cot had passed safety tests.
But Trading Standards conducted their own independent test using Jon Trinci, the director of test-house CPSA (Consumer Product Safety Advice), who failed the cot.
The cot, which had been given to Esther by a family friend, can be folded at the side, allowing mothers easier access to their children.
She had no instructions - something Bednest argued would have negated the risk to Grace.
Bednest declined a full recall of the product, instead offering a ‘modification kit’, consisting of two screws and a small screwdriver, enabling users to prevent the side of the cot from being folded - the feature which led to Grace’s death.
Newer models of the Bednest cot do not have the fold feature.
Experts attended the hearing at County Hall in Horsham to discuss the safety of the cot, and the likelihood to Grace being able to lift her head over the 7cm lip on the side. Several agreed the cot was a danger.
Dr Betty Hutchon, a paediatric occupational therapist, said: “I was horrified when I saw the crib because of the bar going across.”
“For me, it seems very dangerous for a baby and the design is flawed and needs to be changed.”
Sir Alan Craft, an emeritus professor at Newcastle University and a consultant paediatrician, who was giving evidence on behalf of Bednest, argued that the design was ‘inherently safe, when the side is raised to 11cm’.
Coroner Ms Schofield issued a ‘regulation 28’ report to ‘prevent future deaths’ and confirmed she would also be writing to the Secretary of State for business regarding the cot.
Addressing Grace’s parents on the final day of the inquest, she said: “I would like to thank you for the dignity that you have shown throughout this investigation and the inquest hearing.
“It must have been particularly harrowing for you to be faced with the suggestion by Bednest experts over the possible involvement of your daughter Pearl in Grace’s death.
“I do find this unpalatable, particularly as there was no evidence on which to base this proposition.
“I am still not convinced that the company has truly accepted that there was and is a risk of death with the Bednest crib.
“They are of course entitled to rely on the certification by an approved testing house but what has struck me is their lack of compassion over this issue.”
Ms Schofield added: “I am very, very concerned about the number of cots still out there in circulation where the owners are not aware of the modification or perhaps more importantly the number of cot owner who are aware but who do not seem to understand the risk of not using it with a modification kit.”
Ms Schofield said she was concerned that of the 6,000 Bednest sleepers sold, only 45 percent of purchasers had been issued with the modification kits.
“With regard to Bednest, I have concerns about the continued risk that is posed by their product and the fact that there are 55 percent of the customers who still do not have the modification kit.”
After the inquest, Bednest issued a statement saying it ‘apologised for the distress caused to the Rosemans’ and would implement all the coroner’s advice including working to find and fix all the unmodified cots.
A spokesman for the company said: “We take on board all the coroner’s comments following the inquest and apologise for the distress caused to the Rosemans.
“We will implement all the coroner’s advice, immediately actioning recommendations as follows:
• Increasing our communications efforts to convince parents to ensure that the modification must be made to all cribs sold prior to November 2015
• Offering users the option to have their Bednest cribs to be returned to us for us to make the modification and then send back to them if they would rather not fit the two screws themselves.
• Work to find all the remaining unmodified cots in circulation as we have been doing, writing, emailing and calling customers for whom we have contact details. We will create a further social media campaign to promote the importance of the modification and tell parents how to return the crib or make the modification themselves.
“Since the Bednest crib was first launched for sale, the safety of children has been at the heart of our company’s ethos. We have worked with experts and independent test laboratories to ensure compliance with safety standards.
“We were devastated by the news of the death of baby Grace in 2015.”
In response, Esther and Gideon Roseman said they ‘are still very concerned that the public can easily buy the same cot that killed Grace’.