Eleanor Curley-Bennett

I am Emma Serrano, Acting Senior Coroner of Staffordshire.

On the 20 August 2023, I commenced an investigation into the death of Eleanor Curley-Bennett.  The investigation concluded at the end of the inquest on 9 December 2024.  The conclusion of the inquest was a narrative conclusion. The cause of death was: 1a) Positional Asphyxia

i) Eleanor Curley-Bennett, 3 weeks old, was in a baby carrier with her mother, on the 18 August 2023.  She was at a local, family friendly, music festival.  Her mother realised something was wrong and that Eleanor Curley-Bennett, has stopped breathing. ii) She was taken to Festimed, who provided medical care for the music festival.  The carried out basic life support on Eleanor Curley-Bennett, before and during the ambulance journey to the Princess Royal Hospital, Shropshire, where she passed away in the early hours of the morning the following day, the 19 August 2023. iii) During evidence it was disclosed that Festimed did not carry the correct basic life support equipment, in the correct sizing for a baby of Eleanor Curley-Bennet’s age.  Specifically. a) oropharyngeal airway; b) i-gel airway; and c) Tracheal tube.  It was disclosed that there was no intubation equipment available.  It was disclosed that there were no prefilled, diluted, adrenaline that would be suitable to be used on a patient of Eleanor Curley Bennetts age.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.  – i) The lack of availability of the equipment and adrenaline described above

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.