Coroner records 'unascertained' cause of death for Leeds baby boy found unresponsive in bed with his mother

A coroner has expressed his condolences after an inquest was unable to determine a definitive cause of death for a baby boy who was found unresponsive in bed with his mother.
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Wakefield Coroner’s Court heard Prem Parmar died unexpectedly in October 2020 when he was just four months old.

An inquest into his death heard he had been his “usual smiley self” after a bath and a play with toys before he was placed in a double bed with his mother, Nisha Bharath-Parmar that evening.

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Both then fell asleep but when Nisha woke up a couple of hours later, at around 10.20pm, she found Prem unresponsive, with vomit next to him on the bed.

Wakefield Coroner's Court. Picture: SWNSWakefield Coroner's Court. Picture: SWNS
Wakefield Coroner's Court. Picture: SWNS

Paramedics were called and Prem was taken to Leeds General Infirmary where his death was confirmed at 11.15pm.

In the initial aftermath of the tragedy, his family spoke to the Yorkshire Evening Post to say doctors had suspected Prem had died from sudden infant death syndrome (SIDS), which is the unexplained death of an otherwise healthy baby.

But the inquest heard from forensic pathologist Dr Michael Parsons who said he had to give the cause of death as ‘unascertained’.

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He said because sharing a bed - known as ‘co-sleeping’ - was considered an unsafe sleeping arrangement, the existence of this additional “possibility” meant SIDS could not be given as Prem’s cause of death.

He stressed, however, that no evidence had been found in Prem’s post mortem examination of any ‘accidental overlay’ nor any other cause of death.

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The court heard a week before his death, Prem had been taken to A&E by his mother on the advice of a GP, after she described him as “wheezing” and with a pulsating fontanelle.

The inquest heard the family had initially raised questions over the care given during that visit but assistant coroner Oliver Longstaff, who heard from the medic who attended to Prem, said it was clear a “thorough examination” had been carried out.

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Recording an open verdict, Mr Longstaff said: “The circumstances in which Prem died will, to a degree, always have an element of mystery attached to them,” adding: “Every effort to find the cause of Prem’s death has been made by the people whose job it is to do so. And they have not been able to do so.”

And while this is usually sufficient to record the cause of death as SIDS, he said that can only be given when there is no other possible explanation - with the pathologist recording the official cause of death as “unascertained (history of cosleeping)”.

Mr Longstaff said: “He is not saying to me that Prem has died because he was co-sleeping with Mrs Parmar. What he says is because there is a known risk that goes with co-sleeping, the possibility [of risks] of co-sleeping cannot be ignored. This is why the cause of death remains unascertained.”

He sympathised with Prem’s parents - and others - as he said the definition of a safe sleep environment is “incredibly narrow” - namely single occupancy of a suitable cot, with anything other than that deemed unsafe.

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He said: “I would not be surprised if the overwhelming majority of parents would say that [the safe sleeping arrangement] simply doesn't work in reality. But that is what the advice is.

“This family is not the only family that has co-slept.”

He also said it was important to stress that all those who visited the family’s home in Gipton had described how it was “a perfect place for a baby to have been brought up and cared for”.

Prem’s father, Mitesh Parmar, who was present for the inquest, told the court: “I cared for Prem as best as I possibly could,” adding that the couple have gone on to have another baby boy, who is now three months old.

Mr Longstaff said: “It is a good thing to hear that there is a brother - desperately wanted, desperately cared for. I wish you every good fortune.”

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For more information on safe sleep advice, visit the Lullaby Trust at https://www.lullabytrust.org.uk/safer-sleep-advice/

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