A seven-week-old baby died after being found unconscious in her foster mother’s bed.
Honey Rodd had been cared for by Catherine McDonnell since she was five days old but she was found cold and unconscious at around 5am on October 22, 2018 and was pronounced dead in hospital.
An inquest into Honey’s death, which was held at Pontypridd Coroner’s Court on Tuesday, heard how Mrs McDonnell had woken up that morning at around 3am to feed Honey. She said the last thing she remembered was winding the newborn.
On the night that she died, Mrs McDonnell said Honey was wearing a sleepsuit and a bib and described her as a “sicky baby”.
At around 5am, Mrs McDonnell said she woke up, felt Honey’s hand next to her and described it as cold to the touch. She told the inquest that she shouted to her husband who was sleeping in a spare bedroom at the time.
Mrs McDonnell said she had already begun CPR on Honey when Mr McDonnell went downstairs to call 999.
Giving evidence at the hearing, Mrs McDonnell, who has been a foster carer for 15 years and fostered five newborns before Honey, said: “At around 3am I got Honey out of the crib for a feed, the bottle was already made up, I sat up in bed with her and the duvet was up to my stomach.
“Honey didn’t take all of the bottle, I remember winding her, I checked her nappy but she didn’t need changing.
“I woke up about 5am, Honey was lying on her back next to me and she was cold,” said Mrs McDonnell.
Mrs McDonnell said her husband had been sleeping in the spare room at their home in Penarth after he had recently had a hip replacement.
Honey slept in a crib next to Mrs McDonnell’s bed in the main bedroom. But on the night of her death Mrs McDonnell woke on the opposite side of the bed to where she usually slept and Honey was on the side of the bed next to the crib.
Mrs McDonnell said there was no blanket or duvet over Honey when she woke up.
“I started CPR on the bed, I noticed she had been sick and it was like a pink colour, it was not normal sick. When I was doing CPR on her she was bringing more stuff up.”
Mr McDonnell remained on the phone to the 999 controller until an ambulance turned up, and the controller coached Mrs McDonnell through delivering more CPR.
In between the time Mr McDonnell had gone downstairs for the phone and returned to his wife, she changed Honey into a clean sleepsuit.
“When he went downstairs I knew she was gone and that is when I changed her,” said Mrs McDonnell.
An ambulance and paramedics arrived within 12 minutes of the call being made, as well as specialist paediatric doctors from the hospital.
CPR was attempted as well as intubation, which failed at first. Honey was also given glucose and adrenaline.
Her death was confirmed at the Children’s Hospital for Wales in Cardiff at 6.10am.
Mrs McDonnell told the hearing that prior to her death, Honey had been making strange noises during her sleep and this had been mentioned to the health visitor who reassured her it was normal.
Mrs McDonnell also stated that she noticed Honey’s tongue often sat at the top of her mouth, which she was conscious of when feeding Honey and always had to ensure the bottle’s teat was above the tongue.
“She just slept with her tongue to the roof of her mouth all the time,” she said.
“I was worried about her breathing and that week I was going to see the health visitor about it and I had recorded her breathing to show the health visitor,” Mrs McDonnell added.
Other than these concerns, Honey was meeting all her developmental milestones and had no other known health issues.
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A paediatric pathologist report carried out by Dr Andrew Richard Bamber following Honey’s death found no evidence of a tongue tie. But he told the inquest that other issues with a baby’s tongue which could lead to feeding difficulties such as its position or size would not be noticeable post-mortem.
Honey was born four weeks premature on September 1 to mum Paula Rodd.
In a statement read to the court which was recorded at the time of Honey’s death, Ms Rodd said she was happy with the arrangement for Honey’s care and a social worker told the inquest Mrs McDonnell was one of the go-to-carers for newborns in the Vale of Glamorgan area.
After Honey was put in Mrs McDonnell’s care, it was arranged for Ms Rodd to make two-hour visits each day to spend time with Honey.
The inquest also heard evidence from Ms Rodd who said there were no known conditions that could lead to Honey’s death. She informed the coroner that she smoked throughout her pregnancy, but Dr Bamber confirmed this would not have led to her death.
She also informed the inquest of a polyp in her pulmonary artery but Dr Bamber said Honey’s post-mortem found no evidence that she also had a polyp.
Dr Bramber told the court that toxicology analysis carried out on Honey found no drugs, alcohol or substances in her system at her time of death.
Honey’s ribs were fractured, which Dr Bramber said was common in children who had been given CPR.
He said he could not find any evidence that her upper airways were blocked and there were no markings to suggest she had been “rolled on”, adding that there would not always be signs of this if it were the case.
Discussing his findings, Dr Bramber said: “I found a little bit of inflammation in her airwaves which could suggest an infection though I found no evidence of that, but that does not mean she has not had one. I find it very unlikely that has contributed to her death.
“The rest of my findings are negative. I could not find a definite cause of death.”
Dr Bramber went on to discuss how he found small spots of bleeding on Honey’s face as well as some blood in the air space of the lungs, which could be a sign of the airways having become blocked in the context of co-sleeping.
However he also discussed it in the context of her being a noisy sleeper, and the potential that she may have blocked her own airways.
He said the pink fluid found on Honey could have been expelled immediately after her death which is not uncommon in children.
Dr Bramber said co-sleeping increases the risk of Sudden Infant Death Syndrome (SIDS) and the syndrome is also more common in babies who are born prematurely. However he could not give SIDS as a definite cause of death.
Considering all the evidence, he gave the cause of death as unascertained.
Concluding the inquest, coroner Rachel Knight said: “This has been a heartbreaking inquest. I am so sorry to the loss of Honey.
“I find that the foster mother fell asleep after feeding Honey rather than returning her to her cot as is recommended to foster carers.
“The risks associated with co-sleeping are known and were known by Mrs McDonnell and I find the co-sleeping was inadvertent of Mrs McDonnell.
“I find that upon waking, Mrs McDonnell acted immediately to save life. I find that it was likely the liquid has been expelled by Honey before CPR was administered in earnest.
“It is also possible that Honey had an upper airway obstruction caused by her own tongue as she was described as a noisy sleeper and there was difficulty intubating her.
“It is also possible there was a part of time where she was laid on by her foster mother. The medical evidence is not indicative of either of those.
“I don’t have positive evidence Honey died an unnatural death. I don’t have evidence that she died a natural death.
“This is a fact finding exercise based on evidence and not a trial and nobody is to blame. That is not what the coroner is here for.
“The medical cause of death cannot be defined and is listed as 1a unascertained.
“I am unable to say with any degree of probability how Honey came about her death. We simple do not know what happened.
“I am unable to make positive findings of facts either way. All I can do is give a list of probabilities. An open verdict may be recorded.”
Ms Knight said open verdicts are incredibly rare and do not represent a failure of the findings but that there is simply not enough evidence on the balance of probabilities.
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