A coroner has called for urgent action against unregulated maternity services following the tragic death of Steve Bruce’s four-month-old grandson in October 2024.
Steve Bruce’s grandson tragically dies at just four months old (Image: Getty Images)
A coroner has called for urgent national action regarding the unregulated maternity services industry and unqualified maternity nurses following the death of Manchester United legend Steve Bruce’s grandson.
Madison Bruce-Smith tragically died after being laid face down at night against national guidelines on the advice of a woman who called herself an “obstetric nurse” despite having no formal medical qualifications, an inquest heard on Monday. The baby was only 4 months old.
Maddison was found “unresponsive” at her parents’ home in Bowdon, Trafford, at 7am on October 18, 2024, by her father, former Leeds United forward Matt Smith, who is married to Bruce’s daughter Amy.
Coroner Ms Mucci said she would issue a future death prevention report to the Health Secretary calling for regulation of maternity nurses and maternity service companies.
read more: Steve Bruce celebrates birth of new grandson, one year after grandson’s heartbreaking deathread more: Police rule Steve Bruce’s 4-month-old grandson’s death an ‘accident’
The Manchester Evening News reported that a recording of the verdict noted that he had been placed in a “dangerous and face down” sleeping position. “It’s clear there is demand for these services from parents who want some kind of support, but in effect, those who employ them are employing people with little experience or qualifications,” Mucci said.
“Unregulated advice from maternity nurses and maternity services is putting children at risk.”
In a statement, the Smiths said: “The loss of Madison is absolutely unbearable. Our entire family is completely shattered. We will never forgive ourselves for agreeing to sleep on our stomachs. We trusted and believed in Eva Clements’ experience. We trusted her because she was recommended to us.”
“The industry of sleep nannies and maternity practitioners is completely unregulated. Anyone can call themselves a sleep nurse or maternity nanny, with no qualifications, accredited training, safety checks or professional supervision. There are no regulatory frameworks, no mandatory standards, and no mechanisms to ensure competency or prevent dangerous individuals from interacting with newborns. Parents are easily mislead by hints of professionalism.”
Former striker Matt Smith is Maddison’s father (Image: Matt McNulty/Getty)
“We believed that Ruth Asare’s services were structured, vetted, and supervised. We believed that Eva Clements was trained, competent, and operating within a regulated system. None of these assumptions were true.” “Without regulation, something like this will happen again,” they added. “Other parents, like us, will place their trust in individuals who should never be responsible for the care of their infants.”
Bruce said: “Losing Madison is truly unbearable. The pain is indescribable and often unbearable. It has completely shattered our entire family.”
“We believe Madison died in a regulatory vacuum. Without regulation, it will happen again and other parents will trust individuals who should not be caring for their infants.”
Police evidence revealed that Mr Clements was arrested on suspicion of negligence at the time, but after consultation with the Crown Prosecution Service it was deemed that he did not meet the “criminal criteria”.
A senior detective said it was not illegal to have a child in front of her and could not determine whether Ms Clements had “deliberately attempted to harm” Ms Maddison.
The court was told that British medical guidelines, which have been in place for more than 25 years, recommend that babies sleep on their backs.
The inquest heard Ms Clements had no formal training in nursing or midwifery, and she told Maddison’s parents that she had put all four children to sleep on her back.
The court heard the couple had “expressed concerns” about Maddison being in their presence, but she advised them it was “best to stay away from him”.
Bruce was a Manchester United legend as a player and went on to enjoy a successful career as a manager after retiring (Image: Getty Images)
Ms Clements claimed she had attended a one-day course run by Ruth Asare’s company called Lucy Maternity Services. Asare referred to herself as a “postnatal carer” in her testimony, but police noted that her website listed her as an “obstetric nurse.”
Asare admitted he had no formal medical training or qualifications, but those who completed the course were placed on a platform managed by the company. After that, jobs to take care of babies for families began to be created by recommendation.
Detective Chief Inspector Matthew Dixon said both Ms Asare and Ms Clements referred to themselves as “maternity nurses”. “That’s the impression it gives them,” he said, suggesting it may have been to give them more “credibility.”
He noted that Clements “purported to be an expert” and that it was a “major change” to Madison’s normal nighttime routine.
The inquest heard that the couple had sought help and assistance to improve Maddison’s daily sleep patterns. There was a “verbal agreement” that Ms. Clements would look after Madison at night.
She had just met them that day, and during her testimony, she told the court that earlier that afternoon, she had put Madison in front of her to take a nap.
The court heard Mrs Smith sent him a text message just before 11pm asking him to wake her if there was a problem. “I hope he’s ok on the front lines,” she wrote in a text. I’m worried he’s coming forward,” the inquest heard. Clements, who was on the second floor of the house, returned the message about an hour and a half later saying, “Okay, thank you.”
The inquest heard she had sent another person a message that afternoon saying “this baby can cry” along with a “crying emoji”.
Police were also able to find extensive evidence that she was using the app and TikTok on her phone during the night.
The court heard she had a baby monitor and watched it when Maddison woke up in the middle of the night but did not come into the room.
Ms Mucci labeled the use of the term obstetric nurse as “incredibly misleading”.
In her testimony, Asare said it was “unprofessional” to leave a baby on her stomach at night. She claimed she was unaware that Ms. Clements had accepted the job with her family.
But Ms Clements, who has professed love for the baby, said in her evidence that Mr Asare had previously told her that “the baby sleeps best on its stomach” and that it was “okay”. She claimed she told Madison’s parents that she was going to put him on his stomach and they agreed.
Mucci was told that the court had found that “your actions were contrary to those guidelines.”
