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That pursuant to Section 6 1 a Ainslie Alexander Smith, born 14 December died on 4 July between the hours of That pursuant to Section 6 1 b the cause of death was asphyxia and mechanical upper airways obstruction. That pursuant to Section 6 1 c the following are reasonable precautions whereby the accident might have been avoided: This could have been achieved either by the screw fitting that was used in cot beds produced in or by the production, prior to the sale of this cot of the connector which was provided subsequent to the accident.

That pursuant to Section 6 1 d the following are defects in the system of working which contributed to the accident resulting in the death: That fault was that the cot had a split foot end which was not secure and would move during normal use.

Standard design and engineering techniques would have identified the defect and resulted in a modification of the design such as described above. That pursuant to Section 6 1 e there are no other facts that are relevant to the circumstances of the death.

When she returned at about half past ten Ainslie had died. This inquiry was held into that tragic and unnecessary death.

I should say that there was an unfortunate delay in the paramedics arriving as it would appear that their satellite navigation system sent them to the wrong address. Cosatto Ltd, Bentinck Street, Farnworth.

On the morning of the first day of the Inquiry the Crown sought to add a further witness to the Crown witness list. I was advised that this witness who was an officer of Fife Trading Standards who was to give evidence about the notification made by the company in relation to a modification of the cot bed post-accident.

It became apparent that it was to be suggested that the campaign adopted by the manufacturers, Cosatto Limited "Cosatto" was to be criticised. Counsel for Cosatto admitted that if this was to be an issue further evidence may have been required to be led by the company and he would require time to consider the issue.

I voiced certain misgivings as to whether this issue could properly form part of my determination as it was hard to see how it would fit with the terms of Section 6 1 of the Act. After a short adjournment the Crown intimated that they were no longer insisting on raising this issue and would neither lead the new witness nor indeed another trading standards officer who had been on the Crown list of witnesses.

Mr Anderson, on behalf of the family submitted that the issue of the modification campaign could properly form part of the Inquiry. Mr Smith, Counsel for Cosatto submitted that this matter did go beyond the scope of an Inquiry of this sort and reiterated that he would require further evidence, including witnesses from consultants who had been instructed by Cosatto in relation to the campaign. He advised me that Cosatto had taken advice from consultants and that the campaign had been overseen by Bolton Trading Standards.

It appeared that Fife Trading Standards and Bolton Trading Standards may have been at odds as to the appropriate campaign. I considered the issue overnight and in the morning I said that whilst I had misgivings about the relevance of this issue to a Fatal Accident Inquiry I would not stop evidence being led and once evidence had been led it would be open to me to make a determination on that evidence.

I was, however, clear that if this was to be an issue it could not be raised during the course of the time then available for the Inquiry. It would not have been fair to deny Cosatto the opportunity to lead evidence relevant to this matter. I suggested that with consent of all parties it would be open to me to hold the initial Inquiry in relation to the other issues and to continue the Inquiry in relation to the campaign issue as this was an entirely separate and discreet matter.

I was acutely conscious that the family were keen for the Inquiry to proceed as quickly as possible. Having taken instructions Mr Anderson indicated that his clients no longer insisted on raising the issue of the adequacy of the campaign.

The Inquiry accordingly proceeded on the other matters.

The base of the cot is tested up to 20 kilograms and it is usually advisable to stop using this cot when the child can climb out. It became apparent that it was to be suggested that the campaign adopted by the manufacturers, Cosatto Limited "Cosatto" was to be criticised. Can you buy them seperately from anywhere and does anyone know what they are called?

Despite having lodged a list of witnesses, Cosatto led no evidence. After Ainslie's birth he first slept in a Moses basket and then a crib. As he grew the parents looked for an appropriate cot. They searched the internet and visited Baby Land in Kirkcaldy and decided to purchase the Cosatto Stratford cot bed.

This cot was designed to convert, in to a bed as and when required.

cosatto cot bed with drop side Cosatto cot bed with drop side

It had a drop side and the base could be fitted at three levels depending upon the age of the child. The foot end of the cot bed was divided into two parts so that when converted to a bed the foot board was at a lower height than the headboard.

The upper part of the foot board was joined to the lower part by means of two steel pins. These were fixed on the lower part of the foot end and fitted into two holes drilled into the bottom of the top part of the foot board. There was no fixing that prevented the two parts from sliding apart.

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  • The cot was purchased on the 6 June and put together in accordance with the manufacturer's instructions by Mr Smith. The base was installed at the highest level. The cot bed was erected in the middle of Ainslie's room and once erected Mr and Mrs Smith carried it into the corner where Ainslie was to sleep.

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  • Mr Smith carried the foot end and noticed that the top part of the split end was moving away from the lower part. He accordingly carried the bed for the rest of the way by holding on to the lower part of the end.

    Thereafter Ainslie slept in the bed. Because the base was in the top position Ainslie could be lowered over the side of the cot without lowering the drop side. The drop side was only lowered in order to check that it worked during the course of construction and when changing sheets.

    It is agreed by all parties that when the cot bed was moved, the top part of the split foot end rose above its proper position and a rod on which the drop side travelled came out of its cup.

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  • This allowed the drop side to travel on a horizontal plane when minimal force was applied to it. What is equally clear from the evidence that I heard was that this would not have been apparent to Mr and Mrs Smith. At some point after Ainslie had been put to bed on 4 July he had pushed the side of the cot causing a gap to occur through which he slipped. He became trapped between the drop side and the cot base with his face against the mattress. This caused his death. When Mrs Smith discovered him she managed to get him clear but he was white and cold.

    She attempted CPR whilst waiting for the paramedics to arrive and phoned her husband who was checking a patient at his vet's surgery, to come home. A police officer was first to arrive and he started to take over CPR but as Mrs Smith thought that he was being less confident as he was not used to dealing with a small baby, she again took over.

    CPR was continued until the paramedics arrived.

    cosatto cot bed with drop side Cosatto cot bed with drop side

    I should say that there was an unfortunate delay in the paramedics arriving as it would appear that their satellite navigation system sent them to the wrong address. This caused a delay of some 8 minutes however there is no question whatever that this would have made any difference to the final outcome. Ainslie was taken to the Victoria Hospital in Kirkcaldy where he was met immediately by medical staff who made every effort to resuscitate him but this was all unsuccessful and life was pronounced extinct at hours.

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    It was clear from the evidence that I heard that by the time Ainslie had been found there was never any prospect of successful resuscitation. After this accident Cosatto made a modification to the cot bed whereby owners were provided with a metal strap which connected between the two halves of the foot end of the cot bed which removed the dangerous defect which caused this death.

    Regulation 2 of the Regulations provides that a "safe product" means a product which, under normal or reasonably foreseeable conditions of use including duration and, where applicable, putting into service, installation and maintenance requirements, does not present any risk or only the minimum risks compatible with the product's use, considered to be acceptable and consistent with a high level of protection for the safety and health of persons.

    In determining the foregoing, the following shall be taken in to account in particular - a the characteristics of the product, including its composition, packaging, instructions for assembly and, where applicable, instructions for installation and maintenance, Regulation 5 is the general safety requirement and provides that no producer shall place a product on the market unless the product is a safe product.

    Regulation 6 provides a hierarchy of provisions relating to safety starting in paragraph 1 where there are specific rules of law of the community or the United Kingdom laying down health and safety requirements for a particular product.

    This did not apply in this case. Paragraph 2 covers cases where there is a standard contained within the Official Journal of the European Union and again that provision does not apply. There was a European standard which covered cots namely EN When the cot was first designed this standard was dated but it was revised and superseded by a version approved on 2 February There appears to be no material difference between the two standards in so far as they are relevant to the circumstances of this accident.

    Since he has been involved one way or another with toy and nursery product safety. He started working for various testing laboratories and in he began working for Mamas and Papas who manufactured nursery products. He set up a due diligence laboratory as the company wanted to test the products to safety standards. This involved the laboratory being audited by the government run UK accreditation service.

    He now runs his own safety consultancy company. I should say that I found Mr Trinsi's evidence of considerable assistance. He appeared to me to be an expert witness of the highest calibre. He was highly experienced in his field. He produced a full and helpful report. He gave his oral evidence clearly. He expanded on his answers where necessary in order to give clarity to his evidence.

    I detected no hint of any exaggeration during the course of his evidence.

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