A coroner has called for action after the death of baby Madison Bruce Smith, who died after he was placed in an “unsafe sleeping position” in his cot by an unregulated maternity nurse.
The four-month-old grandson of football manager Steve Bruce was found unresponsive by his father, ex-Leeds United and Fulham striker Matt Smith, on the morning of 18 October 2024.
Madison could not be resuscitated at the family home in Trafford, Greater Manchester, and was taken to Wythenshawe Hospital where he was pronounced dead by paramedics.
Mr Smith and his wife, Bruce’s daughter Amy, had employed Eva Clements through a company named Ruthie Maternity Services after their son had difficulties sleeping in the afternoons.
They believed Ms Clements was skilled, fully trained and vetted, and that the company was a well-established maternity and sleep support service, but Stockport Coroner’s Court heard that neither was regulated.
The inquest heard Madison’s parents would “never have dreamed” of putting their son down to sleep in the prone position, but had been advised to by the maternity nurse who they said told them all four of her own babies had slept on their stomachs with no problems.
Young babies are unable to turn themselves over, and NHS advice is that babies should always be placed on their back to sleep to reduce the risk of Sudden Infant Death Syndrome, often called cot death.
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‘Purported expertise’ poses a risk to all children
In a short, narrative conclusion, senior coroner for south Manchester, Alison Mutch, said: “Madison died in circumstances where his cause of death could not be ascertained while asleep in his cot having been placed in a prone and unsafe sleeping position.”
She said the “purported expertise” of untrained people posed a risk to all children where those unregulated services were used.
Issuing a prevention of future deaths report to the Secretary of State for Health, she said: “I hope the services can be regulated and, going forward, parents are not left in a situation where they believe they are employing someone who is qualified to advise them when they are clearly unqualified.”
She said Ms Clements slept in a different room, and had responsibility for checking on Madison, but although he was heard through a baby monitor to stir a number of times during the night, and had cried, she had not gone into his nursery.
Madison’s parents, together with Mr Bruce and his son, ex-footballer Alex, attended Monday’s hearing.
‘Something no family should have to endure’
Mr Bruce, a former Manchester United player, was managing Blackpool at the time of the incident.
He missed the club’s following game, and, in a message posted on the club’s official X account, said: “It’s been the worst time of my family’s entire lives and is something no family should have to endure.”
In a statement read to the court on Monday, Mr Smith said the couple’s son was their “precious, perfect little boy”.
He said: “Losing Madison has been utterly excruciating. The pain is indescribable and often too much to bear. It has totally shattered our entire family.
“We believe that Madison died in a complete regulatory vacuum. Without regulation, this will happen again and other parents will place trust in individuals who should not be in the care of infants.”
What the police investigation concluded
The court heard that police conducted an investigation, and arrested Ms Clements on suspicion of neglect.
Detective Chief Inspector Matthew Dixon, of Greater Manchester Police, said the Crown Prosecution Service was approached for directions and guidance, and it was identified that the criminal threshold had not been met.
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He said this was mainly because such maternity services are unregulated, and that it was not illegal to place a baby on its front.
He added it could not be determined that Ms Clements set out to wilfully harm Madison.
