Coroner's Finding: de-identified FG

0y · Male·suffocation due to overlay by a sleeping adult

A 59-day-old premature infant died from suffocation due to overlay by a sleeping parent. The infant was placed on a mattress next to the parent's cot after refusing to settle in his own cot. Despite the parent's attempt to prevent rolling (positioning on her side with hand placement), she unintentionally rolled onto the infant during sleep, causing fatal suffocation. The death was entirely preventable. Key clinical lesson: infants must always sleep in their own safe sleep surface (cot, bassinet, or approved sleep device), never bed-sharing with adults. Parents require consistent education about sudden infant death syndrome prevention, particularly when fatigued.