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A coroner has demanded action after a newborn baby died with Tramadol in her system after doctors gave it to her mother for her chronic back pain.  

The opioid 'played a role' in her death, the inquest heard.

The mother, who has not been named, suffered chronic back pain caused by her pregnancy and was prescribed the pain killer.

As a result both her and her newborn baby, who has been referred to as Baby S, were kept in Torbay Hospital for three days after the induced birth on September 25, 2018.

The baby died at the family home in Teignmouth, Devon, just two days after being discharged.




Newborn baby, known as Baby S, died with Tramadol in her system after doctors gave it to her mother for her chronic back pain (stock image)

Tramadol was found in her system and is believed to have been passed from breast milk.

Experts at her inquest say they think the drug, or withdrawal from it, 'played a role' in her death.

But the mother has claimed she was told by the hospital she would be fine to breast feed at home despite expressing concerns to them.

And after hearing from experts that there is on-going concern about Tramadol within breast milk, senior coroner Ian Arrow told the family he would be raising concern with the hospital to make sure similar tragedies could be avoided in the future.

The inquest, held in Plymouth, Devon, on Monday, heard a post mortem found no evidence of trauma or mistreatment but discovered there was a 'sub-therapeutic' amount of Tramadol which the pathologist believed may have come from the breast or bottle feeds.




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The pathologist noted that the mother had been prescribed Tramadol by the hospital for her chronic back pain and gave a cause of death as unascertained.

The mother sobbed while telling how she was not going to breast feed her daughter after being prescribed the drug, but claimed the hospital had said it would be okay to do so.

Professor Peter Fleming also attended the inquest to give his expert view as a pediatrician for 40 years.

He highlighted how Tramadol was a 'relatively new drug' and that information on its effects on babies in-utero was still 'really quite new' with some information only being published in the last year.




Because of the mother's chronic back pain, both she and Baby S were kept in Torbay Hospital, Devon, (pictured) for three days after the induced birth on September 25, 2018. Baby S died just two days after being discharged

He said withdrawal from it usually occurs within the first 24 to 36 hours and that traces remaining were usually quite small, but it raised the question as to whether breast-feeding would have any effect and that at this stage the issue was 'unresolved'.

Baby S's grandmother said:  'Surely the hospital should have indicated that? That the danger is the withdrawal. They didn't mention it.'

At this Prof Fleming said: 'I have concerns about the use of Tramadol. There's no absolute answer on that.'

He re-emphasised it was a fairly recently used drug for the past ten years, with it only being more widely prescribed in the 'last three to four years'.

Regarding Baby S's death he said: 'My best answer is that Tramadol played a role.




Professor Peter Fleming told Plymouth Coroner's Court (pictured) that 'Tramadol played a role' in the baby's death

'I can't distinguish whether it's before birth or was complicated by the withdrawal later on.'

To the court itself he stated: 'I think we should be very cautious of Tramadol during pregnancy.'

Senior coroner Ian Arrow stated that he would record Baby S's death as sudden unexpected death in infancy compounded with SIDS.

Referring to the use of Tramadol, he added: 'It maybe, on the balance of probabilities, that the withdrawal may have affected [Baby S] - I can't be sure.

'I will be writing to the hospital that this is something that needs to be carefully considered in the future.'

He told the family he hoped the inquest would give them 'a little comfort' and added: 'I can see that you cared for your daughter immensely.

'I was so sorry to hear of [Baby S's] death.'

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