An inquest is calling for mandatory safe-guarding checks after a baby died after being administered antihistamine by a nanny who likely wanted to 'sedate' him. 

On January 15, 2024, an eight-week-old baby boy was found unresponsive in his crib in the early hours of the morning. 

Resuscitation was attempted and an ambulance was called, but heartbreakingly the baby was pronounced dead at 7am, just 45 minutes after he was found by his nanny. 

At the time, the Metropolitan Police found no obvious cause of death. 

'He was found to have no signs of injury nor neglect and his home environment was in order after scene examination,' the report read. 

But upon further examination the coroner involved in the case, Professor Fiona Wilcox, believes forensic opportunities were missed that may have led to the nanny's prosecution. 

Antihistamine chlorpheniramine - sold under the brand name Piriton - was detected in the baby's bloodstream at the time of death, leading Prof Wilcox to conclude the drug was 'probably administered by the night nanny'.

She added: 'The baby had been described as unsettled and fussy and a baby who woke frequently in the night. 

'The chlorpheniramine was probably administered to sedate the baby to sleep.' 

Whilst most people can safely take antihistamines, the NHS states the drug may not be suitable for children under the age of one. 

Children under six-years-old should not be given medicines that contain chlorphenamine along with other ingredients. 

Antihistamines work by blocking the effects of histamine in the body, which is released when the body detects something harmful, like an infection. 

It causes blood vessels to expand and the skin to swell, which helps protect the body. 

They can also make you feel sleepy which is why doctors sometimes recommend taking drowsy antihistamines, like Piriton, for a short time to help you sleep if your allergy symptoms keep you awake at night. 

But, the NHS warns, it shouldn't be taken solely for sleep problems.

Prof Wilcox continued: 'Expert opinion accepted by the court was that this drug could possibly have caused or contributed to the baby's death, but it could not be found that it probably did.

'Evidence was heard that chlorphenamine causes sedative effects and has been associated with child deaths and should not be administered to a baby this age, except on medical advice to treat conditions such as allergy or itch associated with chicken pox infection. 

'It should not be administered to sedate a child.'  

Reports detailed the nanny had fed the baby twice that evening - but the police did not appear to consider that the baby may have been drugged, despite having a responsibility exclude suspicious circumstances. 

Feeding bottles were not seized for examination and the police failed to look for evidence of medication that could have resulted in the baby's death. 

The nanny was not arrested or interviewed and the property was not searched until October 2024, 10 months after the tragic incident . 

'By then all forensic opportunities had been lost,' the coroner said - an oversight she labelled 'insufficient' given the potential role of poisoning in such cases. 

As a result, the cause of death was listed as sudden unexpected death in infancy.  

'In this case it appears the police were reassured by the home environment and did not consider matters further, including potential third-party interventions such as inappropriate drug administration that may have led to the baby's death,' Prof Wilcox said. 

'As such, forensic opportunities were missed that may have been able to establish that chlorpheniramine had been administered to the baby by the night nanny to the criminal standard.'

Concluding her findings in the prevention of future death report, Prof Wilcox raised concerns that child death investigation teams are 'too easily reassured' when there are no immediate signs of neglect or injury to the deceased child. 

The coroner for inner West London has recommended police training guidelines to be updated and for nannies to be trained not to give Piriton to children without medical advice and parental consent. 

A spokesperson for the National Nanny Association acknowledged that the report highlights 'a serious gap in the regulation of in-home childcare roles'. 

As it stands, the nanny who allegedly administered a drug that have contributed to the death of a child is still working and entrusted with the care of young children.

But the spokesperson added: 'When we continue to see concerned raised at this level, it underlines that this is not about one isolated incident - it's a systemic issue. 

'Parents are placing trust in individuals using professional titles, often assuming a level of training and oversight that simply isn't required. 

'That has to change. We have been calling for mandatory registration, clear standards, and proper safeguarding checks for some time. This report reinforces just how urgent that need now is.' 

Earlier this month, another coroner criticised the 'misleading' use of the title 'maternity nurse' after a four-month-old-baby named Madison Bruce Smith was found unresponsive by his father on 18 October 2024. 

A maternity nurse- who had no medical qualifications other than basic first aid training - had suggested Madison should be placed on his from to help him sleep, despite established medical advice against it. 

The Metropolitan Police and the manufacturers of Piriton have been approached for comment.