“At Ezra's Inquest | was told in evidence that throughout her pregnancy (this being her…”

The coroner’s concerns

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— (1) At Ezra's Inquest | was told in evidence that throughout her pregnancy (this being her first pregnancy) i (Ezra's mother) did not see the same midwife twice. | believe that there should be some level of continuity of care in antenatal appointments to ensure that all of the necessary checks are preformed and appropriate antenatal advice is shared with the mother. (2) | was also heard that iii own personal pregnancy was uneventful but | am concerned that the distinct lack of continuity of care appears to expose a risk that should there be any abnormalities and/or risk factors to either mother or baby as the pregnancy develops, that these have the potential to be missed; either entirely misses or not properly communicated to whichever midwife conducts the next antenatal appointment, causing significant risk to both mother and baby. | believe that there is a serious risk of future death posed by this lack of continuity of care. (3) At Ezra's inquest | was told that as baby had been delivered safely with no significant injuries to mum (i.e. no significant tearing or blood loss) that the family were encouraged to leave fairly rapidly. On discharge, the focus of information sharing and care was distinctly focused on after-care for the mother. The family did not recall being given any information directly on safe-sleeping; either at antenatal appointments or at a post-natal stage from any midwife or , Health Visitor. Any information they were given was provided almost as an after-thought and given in the form of a leaflet which it was suggested that they read. | was told that the first HV appointment the family received was approximately seven weeks after Ezra had been born. | believe that 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. (4) | also heard that midwives are unaware that causing the death of an infant due to co-sleeping becomes an automatic criminal offence of "overlay" (under section 1(2) of the Children and Young Persons Act 1933) if alcohol and/or drugs are involved. | believe that making this information readily available to midwifery practitioners may reduce the risk of future infant deaths due to co- sleeping but may also reduce the need for Police involvement (with a view to prosecution) in what is already a tragic time for a family who have lost their child.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0222

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0