SINGAPORE - Just weeks before her death, a baby girl had to be attended to when she cried after she got trapped in a gap between a mattress and the bed rail.
Early this year, seven-month-old Yuri Chua Le En, who slept in her own room, ended up in the same spot again - this time with fatal consequences.
On Jan 15, at around 7am, her father went to check on her and found her unresponsive.
The police were alerted and paramedics who came to the family's Jurong East flat pronounced the baby dead at the scene.
Her parents were not named in court documents.
A forensic pathologist later certified her death to be consistent with suffocation.
Following an inquiry last Friday (Oct 4), State Coroner Kamala Ponnampalam found Yuri's death to be an "unfortunate misadventure".
She said that according to the pathologist, a developmentally normal seven-month-old baby can usually roll around on a bed but is unable to crawl or climb effectively.
As a result, when the baby accidentally rolls into a gap, it is unlikely that he or she can climb out of it.
The state coroner added that the paediatricians and those involved in infant care regularly emphasise the ABCs of safe sleep - "alone, back and crib".
State Coroner Kamala said: "The infant should not sleep in the same bed as others but not necessarily in a different room. There is always a risk of suffocation... when a larger person rolls over and the infant's airway becomes blocked."
She also said infants should always be put to sleep on their back, as this is found to be the safest sleeping position for them.
They should also sleep in a "well-built crib, free of loose bedding, pillows and toys, which could cause entrapment or suffocation".
Yuri's parents had arranged for their daughter to sleep alone in a bedroom since December last year.
Their intention was to allow her to transition to the next stage of her development, said the state coroner.
The couple were also unwell at the time and did not want to infect their child by sleeping in the same room.
On Jan 14, Yuri's mother breastfed her at around 7pm and patted her to sleep.
The father checked on Yuri at around 7am the next day and found her body "almost fully trapped" in the gap between the mattress and the padded bed rail.
Paramedics pronounced her dead at around 8am.