Alexandra Smith found her lifeless son wedged between the mattress and the side of the cot, which had moved to create a dangerous gap.
By the time of the baby’s death at his home in Pitlessie, Fife, manufacturer Cosatto had already introduced an alteration to the Stratford Cot Bed that would have prevented the tragedy, the inquiry at Cupar Sheriff Court found.
A further alteration was made after Ainslie’s death, when the company developed a safety strap for the model.
A lawyer for the baby’s parents said the couple felt “vindicated” by Sheriff Charles Macnair’s ruling.
In his finding, he said: “There was no dispute that this cot bed had a defect which rendered it unsafe. There were at least two alterations which could have been made to the design of the cot bed sold to Mr and Mrs Smith which would have avoided the death.
“Firstly, there is the insertion of a screw through the pin. This modification had been made prior to the sale of the cot bed to Mr and Mrs Smith, but it would appear that old stock was still being sold to customers after that modification had been introduced.
“The other alteration which would have prevented the death was the modification by a safety strap holding the two parts of the split end together. Such a safety strap was provided post-accident.”
The earlier modification was made to prevent the upper and lower sections of the cot’s adjustable foot-board from
moving under pressure by adding a screw and joining pin.
This held the upper part of the foot-board in place, preventing the creation of a gap. After Ainslie’s death, the company provided a metal strap to bolt to the front left-hand cot leg, clamping the upper and lower sections of the foot-board together.
The cot was bought in Baby Land, Kirkcaldy, on 6 June, 2009, after the couple researched the item online. It was put together according to the manufacturer’s instructions by the baby’s father, also called Ainslie.
After the baby was put to bed on the evening of 4 July, 2009, he managed to push the side of the cot, creating a gap through which he slipped.
He became trapped between the drop side and the cot base, with his face against the mattress, causing death by asphyxiation.
Mrs Smith tried to revive him and called an ambulance, but paramedics were delayed by about eight minutes because their satellite navigation system sent them to the wrong address. However, the delay would not have made any difference to the outcome, Sheriff Macnair said.
The inquiry heard evidence in February from safety consultant John Trinsi, who suggested the defect should have been picked up during testing of the cot.
The sheriff said: “I accepted the evidence of Mr Trinsi where he considered it inconceivable that the defect would not have been noticed during the process of design, manufacture and testing.
“It is theoretically possible that the defect was not noticed until the testing stage and that the testing organisation did not draw it to the company’s attention but, without positive acceptable evidence of that happening, I am not prepared to make the finding sought on behalf of the company.
“Equally, it would not be appropriate for me to make a finding that they did know of the defect, as that would be going beyond the scope of this inquiry.”
After Ainslie’s death, Cosatto issued a product safety notice that said: “If moved or lifted for any reason, we found it possible to create a gap between the lower and upper cot bed leg sections, with the possibility of injury to parent or child. It was also found possible that, in some cases, partial disassembly of the drop side mechanism could occur, rendering the cot unsafe.”
The company subsequently provided owners of the Stratford model with a metal strap that connected between the two halves of the foot end of the cot, removing the hazard.
Mr Trinsi told the inquiry that, at some point before Mr and Mrs Smith bought the cot, the company, based in Bolton, Lancashire, had made the screw and pin modification that would have made the cot safe.
He said he had been advised that the reason for this was that it was intended to make the cot into a three-way model, meaning it could be made into a cot, a bed and a sofa, the sheriff said. “He did say, however, that the instructions which he had for the modified cot made no mention of conversion to a sofa.”
Responding the inquiry’s findings, a Cosatto spokesman said: “We accept the sheriff’s determination and take on board all comments made during the hearing.
“We have complied with every aspect of this investigation and remain committed to continual improvement of product safety.
“Our thoughts and condolences remain with the Smith family. It would be inappropriate to make any further comment at this time for legal reasons.”
The Smiths’ lawyer, Anthony Anderson, said the couple hoped the inquiry would help prevent similar future tragedies.
He said: “My clients are more than satisfied with today’s determination and believe it has vindicated their efforts to fully investigate the circumstances leading to the sudden death of their baby son.
“Whilst they have always known this tragedy could have been avoided, the fatal accident inquiry has undoubtedly established clear defects in the design and construction of the Cosatto cot.”
He added: “They only hope that the sheriff’s findings will now go some way to ensure that the circumstances surrounding their heartbreaking ordeal do not befall another family.”