Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0179, written 26 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Mar 2026 |
|---|---|
| Reference | 2026-0179 |
| Deceased | Madison Smith |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of Manchester South 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 28th October 2024 I commenced an investigation into the death of Madison James Bruce SMITH. The investigation concluded at the end of the inquest on 23rd March 2026. The conclusion of the inquest was narrative: Died in circumstances where his cause of death could not be ascertained whilst asleep in his cot having been placed prone in an unsafe sleeping position. The medical cause of death was unascertained. 4 CIRCUMSTANCES OF THE DEATH Madison James Bruce Smith was born on 1st June 2024. He was a healthy baby who lived with his parents. Due to concerns about his pattern of sleeping during the day his parents engaged a person who described themselves as a maternity nurse. The maternity nurse was listed on a maternity agency platform. Any person can describe themselves as a maternity nurse or a sleep nurse or a post-natal nurse. No qualifications are required and there is no regulation of persons holding themselves out as maternity nurses or the agencies that offer training courses or their services. In this case the maternity nurse and the owner of the agency had no medical qualifications other than a basic first aid qualification. The use of the word nurse gave the impression of a level of knowledge and skills that were not present. The maternity nurse placed Madison in his cot in a prone position to sleep on the night of 17th October. The placing of a baby of his age in such a position is contrary to all national guidance in relation to safe sleeping and is known to be a significant risk factor for the sudden and unexpected deaths of babies. He should not have been placed in a prone position. Madison stirred several times in the night. He was not checked other than visually via a monitor or once at a distance to ensure he was coping with the unfamiliar sleeping position. The maternity nurse had taken responsibility for checking on him. He should have been checked on closely particularly when he cried. At 7am on 18th October 2024 he was found unresponsive by his father in his cot. He was taken to Wythenshawe Hospital where Doctors confirmed he had died on 18th October. A post-mortem examination was unable to give a cause of death. However, it was identified that prone sleeping created an increased risk of his sudden unexpected death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1.The inquest heard evidence that there is a significant demand from families with very young children who would like to get their children into a sleep routine at an early stage. To meet that demand there are now agencies and individuals who seek to meet that demand. However, the inquest was told that there is no statutory regulation of these individuals or of the agencies. Consequently, anyone can set up an agency that purports to offer training and expertise in maternity services. They need not have any formal training or any medical qualification. The courses they offer do not need to be quality assured or meet any minimum standards. 2. Anyone the inquest was told, can attach the term nurse to a word such as night/maternity/ post-natal. The inquest was told that only the term registered nurse is protected and restricted in its use. An individual who has no medical training or formal early years training can offer their services to a family with young children describing themselves as for example a maternity nurse. This can the inquest was told give a misleading impression of their expertise and skill set to a family employing them. A statutory bar on the word nurse being used by anyone other than a registered nurse on the NMC register would avoid this situation from arising. 3.The inquest was told that the promotion of prone sleeping by unqualified individuals describing themselves as maternity nurses and experts in sleeping poses a very significant risk to a young baby. A baby will sleep more deeply in a prone position which is why superficially it can seem to be a solution where a baby sleeps poorly. However, whenever a young baby is placed in such a position it will increase the risk that they will die suddenly and unexpectedly. All health professionals need to be vigilant in continuing to emphasise the national guidance on safe sleeping and be vigilant in flagging up to a family that prone sleeping in a child that cannot independently turn over is not a solution to a poor sleep routine but rather is a factor that increases the risk of a sudden and unexpected death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st May 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following interested persons namely the Family, Ruthie Maternity Services, , Child Death Overview Panel who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch OBE Senior Coroner 26/03/2026
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU HM Coroner Alison Mutch OBE Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 11 May 2026 Dear Ms Mutch, Thank you for the Regulation 28 report of 26 March 2026 sent to the Secretary of State for Health and Social Care about the death of Master Madison James Bruce Smith. Firstly, I would like to say how saddened I was to read of the circumstances of Master Smith’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the lack of statutory regulation of individuals or agencies purporting to offer training and expertise in maternity services; that anyone can attach the term ‘nurse’ to a word such as ‘night’, ‘maternity’ or ‘post-natal’; and the risk posed to a young baby by the promotion of prone sleeping. In preparing this response, Departmental officials have made enquiries with NHS England to ensure we adequately address your concerns. Regarding statutory regulation and the protection of the title ‘nurse’, I understand your concern that none of the roles mentioned in your report (‘maternity nurse’, ‘sleep nurse’ or ‘post-natal nurse’) are regulated professions, and that anyone can set up an agency that implies training and expertise in maternity services without any formal training or any medical qualification. As you are aware, the Nursing and Midwifery Council (NMC) is the independent regulator of nurses and midwives in the UK, and nursing associates in England. It is a criminal offence for a person to claim, with intent to deceive (whether expressly or by implication), that they are on the NMC Register when they are not, to use a protected title to which they are not entitled, or to falsely claim that they have qualifications in nursing or midwifery. As you point out, currently, the title ‘registered nurse’ is protected in law. This is obviously not enough to safeguard the public, and we are taking action to address the misuse of the trusted title ‘nurse’ by unregulated professionals. As part of reforms to the NMC’s legislative framework, we will create a new protection of title offence, making it a criminal offence for anyone who is not a registered nurse with the NMC to call themselves a nurse (with some limited, specified exceptions). The term ‘nurse’ is used across multiple professions – for example, ‘dental nurse’ and ‘veterinary nurse’ – and it is not our intention to prevent the legitimate use of the title ‘nurse’ in these instances. The legislation will therefore include exemptions to allow other professionals to use the title legitimately, and later this year we will be seeking views on which roles should be exempted. The Government will continue to work with key stakeholders, including the NMC, the devolved governments, the Royal College of Nursing, trade unions, other professional representatives and the social care sector, on developing the protection of title offence. Regarding safe sleeping guidance, I understand the risk posed to young babies by the inappropriate promotion of prone sleeping by unqualified individuals. Guidance published by the National Institute for Health and Care Excellence states that all maternity services should provide advice to parents postnatally on safe sleeping, including that babies sleep on a firm, flat mattress, lying on their back. NHS England also provides advice online at NHS.UK. This includes how to reduce the risk of Sudden Infant Death Syndrome (SIDS) and includes links to guidance from The Lullaby Trust. NHS England further emphasises the importance of consistent, evidence-based messaging from maternity and neonatal professionals. All parents should receive information about established guidance on safer sleeping at antenatal, postnatal and health visiting contacts. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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