A four-month-old boy from Bowdon died after an unregulated maternity nurse placed him on his front to sleep, an inquest has heard.
Madison Bruce Smith - grandson of football manager Steve Bruce - was found unresponsive by his father, former Leeds United striker Matt Smith, at the family's Bowdon home on October 18th 2024.
Matt and his wife Amy, daughter of Steve Bruce, had hired Eva Clements through Ruthie Maternity Services after Madison struggled to sleep in the afternoons. The couple believed Clements was skilled, trained and properly vetted, and that the agency was well-established. Neither the nurse nor the service were regulated.
A narrative conclusion at Stockport Coroner's Court found Madison had been "placed in a prone and unsafe sleeping position", though his cause of death could not be formally ascertained.
Senior coroner for south Manchester, Alison Mutch, issued a prevention of future deaths report to the Secretary of State for Health, calling for the regulation of maternity services.
She warned that the "purported expertise" of untrained individuals posed a risk to children, adding: "In effect, any of us could leave the building today and call ourselves a maternity nurse."
The inquest heard that Clements had advised the family that all four of her own babies had slept on their stomachs without issue - advice directly contrary to NHS safe sleeping guidance. Madison's parents said they would "never have dreamed" of placing him in the prone position had it not been for that advice.
Ruth Asare, head of Ruthie Maternity Services, told the court she held no medical qualifications - only a first aid certificate and a Level 2 diploma in post-natal care obtained through a three-day course and a six-month project. Ruthie Maternity Services charged £450 for one-day training courses.
Clements, who held a degree in early years education, denied telling Amy she was a nurse and denied persuading the family the prone sleeping position was safe. She said she had been taught by Asare to place babies on their stomachs - a claim Asare disputed.
Greater Manchester Police arrested Clements on suspicion of neglect, but the Crown Prosecution Service determined the criminal threshold had not been met, in part because placing a baby on its front is not illegal.
In a statement read to the court, Matt Smith said: "Losing Madison has been utterly excruciating. We believe that Madison died in a complete regulatory vacuum. Without regulation this will happen again."
Steve Bruce, who was managing Blackpool FC at the time, attended the hearing alongside his son Alex, a coach at Salford City. In a message posted after Madison's death, Bruce said it had been "the worst time of my family's entire lives."
