A coroner has called for urgent action over unregulated maternity services after the tragic death of Steve Bruce’s four-month old grandson in October 2024
A coroner has issued an urgent call for national action concerning the unregulated ‘maternity services’ industry and ‘maternity nurses’ lacking formal qualifications, following the death of Manchester United legend Steve Bruce’s grandson.
Madison Bruce-Smith tragically passed away after being put to bed on his stomach at night, contrary to national guidelines, based on the advice of a woman claiming to be a ‘maternity nurse’, despite having no official medical qualifications, an inquest heard on Monday. The infant was just four months old.
Madison was found ‘unresponsive’ at 7am at the family residence in Bowdon, Trafford, on October 18, 2024, by his father, ex-Leeds United forward Matt Smith, who is married to Bruce’s daughter Amy.
Coroner Ms Mutch said she would be issuing a prevention of future deaths report to the health secretary calling for the regulation of maternity nurses and maternity services companies.
READ MORE: Steve Bruce celebrates arrival of new grandchild a year on from heartbreaking death of grandsonREAD MORE: Death of Steve Bruce’s four-month-old grandson is ruled an ‘accident’ by police
The Manchester Evening News reports that she recorded a narrative verdict, noting he was placed in a ‘prone and unsafe’ sleeping position.Ms Mutch said: “The demand for these services from parents hoping to have some support is clearly there, but in effect, anyone who is employing them is employing somebody who may have little experience or qualifications.
“The unregulated advice given by maternity nurses and maternity services puts children at risk.”
In a statement, Mr and Mrs Smith said: “Losing Madison has been utterly excruciating. It has totally shattered our entire family. We will never forgive ourselves for agreeing to tummy sleeping. We relied and trusted on Eva Clements’ experience. We trusted her because she was recommended to us.
“The sleep nanny and maternity practitioner industry is entirely unregulated. Anyone can call themselves a sleep nurse or a maternity nanny without any requirement for qualification, accredited training, safeguarding checks or professional oversight. There is no regulatory framework, no compulsory standard, and no mechanism to ensure competence or prevent unsafe individuals from working with newborn babies. Parents are easily misled by language that implies professionalism.
“We believed Ruth Asare’s service was structured, vetted and supervised. We believed Eva Clements was trained, competent and operating within a regulated system. None of those assumptions were true.” “Without regulation this will happen again,” they added. “Other parents, just as we did, will place trust in individuals who should never be responsible for the care of infants.”
Bruce said: He said: “Losing Madison has been utterly excruciating. The pain is indescribable and often too much to bear. It has totally shattered our entire family.
“We believe that Madison died in a complete regulatory vacuum. Without regulation this will happen again and other parents will place trust in individuals who should not be in the care of infants.”
Police evidence revealed that Ms Clements was arrested on suspicion of neglect at the time, but the ‘criminal threshold’ was not deemed to have been met after consultation with the Crown Prosecution Service.
A senior detective stated it wasn’t illegal to place a child on their front and it couldn’t be determined if Ms Clements ‘wilfully set out to deliberately harm’ Madison.
The court was informed that UK medical guidelines, which have been in place for over 25 years, advise that babies should sleep on their backs.
The inquest heard that Ms Clements had no formal nursing or midwifery training – and she told Madison’s parents that she put all her four children to sleep on their fronts.
The court learned that the couple ‘expressed concern’ about Madison being on his front, but she advised them to ‘best leave him’.
Ms Clements claimed she attended a day-long course with a company named Ruthie Maternity Services, run by Ruth Asare. In her testimony, Ms Asare referred to herself as a ‘post-natal carer’, but police noted the website mentioned ‘maternity nurses’.
Ms Asare admitted she had no formal medical training or qualifications, but those who completed the courses were placed on a platform managed by the company. Jobs caring for babies for families would subsequently come from recommendations.
Detective Chief Inspector Matthew Dixon stated that both Ms Asare and Ms Clements referred to themselves as ‘maternity nurses’. He said ‘that’s the impression they were giving’ and suggested it could have been to enhance their ‘credibility’.
Ms Clements, he noted, was ‘purporting to be a professional’ and that it was a ‘massive change’ in Madison’s usual night-time routine.
The inquest heard that the couple sought help and support to improve Madison’s daily sleep pattern. There was a ‘verbal agreement’ that Ms Clements would care for Madison during the night.
She had only met them that day and whilst testifying, told the court she had put Madison down for a nap on his front earlier that afternoon.
The court heard Mrs Smith sent her a text message just before 11pm asking her to wake her up if there was any issue. She wrote in the text ‘I hope he is okay on his front. I worry about him being on his front’, the inquest heard. Ms Clements, who was upstairs in the house, messaged back approximately an hour and a half later saying ‘okay, thank you’.
The inquest heard she had sent a message to another individual that afternoon saying ‘this baby can cry’, accompanied by a ‘crying emoji’.
Police were also able to uncover extensive evidence of her using apps and TikTok on her phone during the night.
The court heard she had a baby monitor and observed Madison on it when he woke up during the night, but didn’t enter his room.
Ms Mutch labelled the use of the term maternity nurse as ‘incredibly misleading’.
In her testimony, Ms Asare stated that leaving a baby unattended on their tummy at night was ‘unprofessional’. She claimed she wasn’t aware that Ms Clements had taken a job with the family.
However, in her own evidence, Ms Clements, who professed her love for babies, said Ms Asare had previously told her that ‘babies sleep better on their tummies’ and that it ‘was okay’. She alleged she informed Madison’s parents of her intention to put him down on his tummy, and they consented to it.
Ms Mutch informed her that the court had ‘established that what you were doing was contrary to that guidance’.
