Ocean-Leigh Hayes

I am Rachel Knight Assistant Coroner for the coroner area of South Wales Central.

On 29 December 2021 I commenced an investigation into the death of Ocean-Leigh Pauline Jean Hayes. The investigation concluded at the end of the inquest on 15th November 2023. The conclusion of the inquest was Sudden Unexplained Death in Infancy, as there was insufficient evidence of any other natural or unnatural factor. 1a Sudden Unexplained Death in Infancy

These were recorded as : Ocean-Leigh Pauline Jean Hayes was aged 4 months when on 22nd December 2021, she died at her home address of 58 Snowden Road, Ely, Cardiff. Ocean had been co-sleeping with her mother in the hours and minutes before she died. The Inquest focused upon: a. The arrangements for sleeping with a newborn infant and the pathology evidence.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will 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)    Guidance requires health visitors to physically review sleeping arrangements before the baby is 6 weeks old. (2)  I heard evidence that this was not always being done. (3)  There may be missed opportunities to physically risk assess sleeping arrangements including inter alia bedding, blankets, pillows, mattress and positioning, particularly where co-sleeping is a factor, and missed opportunities to advise parents on risks they may be taking.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.