Additionally, there was no guidance on whether the slats should be oriented with the strapping on the top side or the underside of the bed.
The space between the floor and the slat bed base was about 28cm – big enough for a small child to crawl under.
The night before the toddler was found unresponsive, his grandmother checked on him multiple times, with the last check being at 10.30pm, the findings state.
She recalled that on the final time, she could see her grandson asleep in his bed.
The next morning, the toddler’s mother went to check on him around 10am.
Seeing the boy from under the bed, she thought her son was hiding from her and pulled the duvet back.
But the toddler was unresponsive, with a portion of the strapping from the bed slats tightly wrapped around his neck.
An ambulance was called; strapping was cut from around the boy’s neck, and CPR was performed.
Upon arrival, ambulance staff continued resuscitation attempts, but the toddler could not be revived and was pronounced dead shortly after.
The report outlined that no person in the house described hearing any unusual noises during the night.
It also indicated there were some toys under the bed, and it was possible the boy was trying to retrieve something when the fabric strap attached to the bed slats became wrapped around his neck, preventing him from freeing himself.
Coroner Thomas’ report stated that the toddler’s bed, and the updated model of his bed currently for sale, was not inherently safe because of the risk of strangulation.
The report outlined that to become an inherently safe product, the design must eliminate the risk of strangulation. But with the fabric strapping remaining as part of the design on the bed, the risk remained.
‘Fabric strapping is unnecessary for the bed’s structural integrity’
Coroner Thomas’ report stated that using metal screws to secure the bed slats to the inner base indicated the fabric strapping was not necessary for the bed’s structural integrity.
Instead, the strapping might only be intended to simplify packaging and keep the slats together before assembly.
The Warehouse Group said the fabric strapping was necessary to correctly space the slats during set-up and to help disperse weight when weight was applied to a small area.
But Coroner Thomas outlined in her report that if the staples and fabric straps were meant to contribute to the bed’s structural integrity, testing done after the child’s death indicated that its strength was inadequate.
Following the toddler’s death, the Warehouse Group updated the bed assembly manual to specify that the strapping should be oriented on the topside of the slats, added a red warning sticker, and increased the number of staples used to attach the straps to the slats.
However, the coroner said these changes were insufficient.
She indicated as her primary recommendation that improved assembly instructions, warnings about the risk of strangulation, and increasing the pull strength of the fabric strapping with more staples were all secondary to “the most effective prevention solution”, which was to design the problem out of existence.
Coroner Thomas recommended that the Living & Co single slat bed be redesigned to eliminate the fabric strapping that contributed to the toddler’s death.
The redesign should also incorporate alternative methods to ensure that the slats were securely fastened to the base with appropriate spacing.
The Warehouse Group
said in its report that it was collaborating with a supplier to remove the strap from the bed design and to use other methods for strengthening and placement, discontinuing the use of any design that incorporated these straps.
Coroner Thomas also recommended The Warehouse Group ensure all the website pictures, diagrams and box packaging pictures for the bed were consistent and showed the strapping affixed to the topside of the bed slats – not the underneath.
The instruction manual for the bed now includes an instruction to place the straps on the top of the bed and a warning that failure to put the straps on the topside of the slats could be a strangulation hazard beneath the bed. The 2021 manual did not include this.
A red warning label has also been added to the bed to reiterate the same message.
This updated manual will accompany all their currently held stock.
It reiterates a key recommendation that the bed be redesigned to remove the need for strapping altogether, or that the current fabric straps be replaced with a stiffer, less pliable material.
The Warehouse Group stated that before placing any further orders, it will explore with its supplier a way to remove the fabric strapping from the design entirely.
In addition, Plunket has updated its online child-safety guidance to alert parents to the dangers of loose straps under slat-bed frames.
Jazlyn Whales is a multimedia journalist based in the Christchurch newsroom.