Madison Bruce Smith, a four-month-old baby and the grandson of football manager Steve, 65, was found unresponsive by his father Matt Smith, a former Leeds United striker, at the family home in 2024.
A hearing at Stockport coroner’s court has now been told Madison had been put to sleep on his front by Eva Clements, who had been hired by his parents Amy Smith and Matt through Ruthie Maternity Services.
The couple believed Eva was trained and vetted, and that the agency was established, but the court heard neither the individual nor the service was regulated.
Alison Mutch, the senior coroner for south Manchester, recorded a conclusion Madison’s cause of death could not be ascertained after he had been “placed in a prone and unsafe sleeping position”.
She said: “I hope the services can be regulated and, going forward, parents are not left in a situation where they believe they are employing someone who is qualified to advise them when they are clearly unqualified.
“We have been told that in effect any of us could leave the building today and call ourselves a maternity nurse as while the term ‘registered nurse’ is strictly controlled, the term ‘nurse’ is not.
“It gives an illusion of someone who is highly trained and able to support parents.”
The inquest heard Eva had been employed after Madison experienced difficulty sleeping in the afternoons.
Ruth Asare, head of Ruthie Maternity Services, told the court she had no medical qualifications beyond a first aid certificate and a Level 2 diploma in post-natal care obtained through a three-day course and a six-month coursework project.
Eva said she held a degree in early years education but accepted she had no medical qualifications.
Evidence showed Madison’s parents would “never have dreamed” of placing their son to sleep on his front, but followed advice attributed to Eva, who was said to have told them her own children had slept that way without issue.
The court heard she slept in a separate room and did not check on Madison during the night despite hearing him stir and cry on a baby monitor.
Matt said in a statement read to the court: “Losing Madison has been utterly excruciating. The pain is indescribable and often too much to bear. It has totally shattered our entire family.”
He added: “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.”
Ruth said those trained by her organisation were instructed to place babies on their backs, while Eva said she had been taught to place babies on their stomachs.
Eva denied telling Amy she was a nurse and denied “convincing her” that the prone position was appropriate.
Matthew Dixon, a detective chief inspector with Greater Manchester Police, said officers investigated the case and arrested Eva on suspicion of neglect.
He said the Crown Prosecution Service determined the criminal threshold had not been met, adding it was not illegal to place a baby on its front and it could not be established she had intended to cause harm.
