A coroner will ask health bosses to tighten up measures ensuring healthy sleeping arrangements for babies after the unexplained death of a six-month-old boy.
Lydia Brown, assistant coroner for Leicester City and South Leicestershire, is writing to managers at the Leicestershire Partnership NHS Trust, to ensure its health visitors carry out more thorough investigations into the living conditions of families with very young children.
It follows the death of Lewis MacDonald, from Eyres Monsell, Leicester, on February 19.
An inquest at Leicester Town Hall was told he died from "unascertained causes" – in what the coroner described as a "sudden, unexpected death in infancy".
Giving evidence, pediatric pathologist Dr Nicholas Ostojic said: "The previous evening he was fed and put to sleep on a settee, where his grandmother also slept, but on the other side.
"In the morning, when the grandmother woke up, she realised that the baby was blue and unresponsive."
Lewis could not be revived.
The inquest heard Lewis had surgery to remove a tumour from his spine shortly after his birth but had fully recovered.
During the healing process he had developed a habit of sleeping on his stomach, which was the position he was found in on the morning of his death.
However, there was no evidence to suggest this could have been a contributory factor.
Dr Ostojic said: "I wasn't able to identify anything to actually give a medical cause of death."
The inquest heard Lewis was a happy, loved and well-cared for baby.
He lived with his grandmother, Carol Calow, mother Laura Calow and three other siblings.
The family was regularly visited by social workers and health visitors, who provided information about safe sleeping arrangements for babies and NHS guidelines on factors which professionals consider may increase the risk of cot death. They include a baby sleeping on its front; sharing a bed with an adult, smoking around an infant, and adults sleeping with a baby on a settee or armchair.
Giving evidence, health visitor Sara Chamberlain, who is based at Eyres Monsell Children's Centre, also in Hillsborough Road, said she was unaware that Lewis had been sleeping on a settee.
She assumed he was still sleeping in a Moses basket.
Coroner Lydia Brown asked her why, given the NHS cot death "pointers", his sleeping arrangements were not looked into more thoroughly.
Ms Chamberlain replied: "I now realise that maybe I should have," adding that in "hindsight" more regular visits should have been made to a family in this position .
She said that this was now a matter routinely discussed at team meetings when dealing with other families in similar circumstances.
Ms Chamberlain said additional advice on sleeping arrangements was also now given to families when babies are four months old, but said it was a decision made by her team and was not official NHS Partnership Trust policy.
Mrs Brown recorded a narrative verdict, in which she accepted Lewis's sleeping arrangements did not constitute "co-sleeping".
She said: "There is no evidence that any one factor either caused or contributed to Lewis's death."
However, Mrs Brown said she would be writing to the Leicester Partnership Trust, and would ask them to consider making the four-month sleeping arrangements check official policy.
She said she would like to see a "more robust approach" where a baby's environment contains cot death risk factors.
After the inquest Laura Calow said: "Lewis was the beautiful baby boy I'd always dreamed of. I'm heartbroken. I loved him with all my heart."
