What happened
She was nine months old and attended a private day nursery in Stockport. On 9 May 2022 she was put down to sleep in the baby room at about 13:35.
Tightly swaddled so that her movement was severely restricted, she was fastened into a harness and placed face down on a bean bag, a blanket at least partly over her head. She stayed there until 15:12, when the member of staff found she was not breathing. She was pronounced dead at hospital.
The trial judge, Mrs Justice Ellenbogen, said CCTV showed her distress was “readily apparent, both visibly and audibly”. The pathologist certified death from asphyxia and pathophysiological stress caused by an unsafe sleeping environment.
The outcome
A jury convicted Kate Roughley of unlawful act manslaughter. At Manchester Crown Court on 22 May 2024 she was sentenced to fourteen years; the judge found to the criminal standard that the baby was left face down, tightly swaddled and harnessed, and told her the death was “absolutely avoidable”.
The jury rejected her evidence that the baby was on her side, that the harness did not restrict movement, and that checks from across the room were adequate. The judge found the base offence was child cruelty.
What went wrong
The baby was sleeping on equipment that was not a bed. Policy required babies on their backs on a firm, flat surface, and two cots were free that afternoon. The judge found the bean bag was used so as not to use up a cot, and that a baby placed on one was in obvious danger.
Nobody classed it as restraint. Swaddling, a harness and a face-down position hold a baby still. Treated as sleep practice, it was never planned, agreed or reviewed.
Checks were visual and from a distance, which the judge heard was woefully inadequate for a baby of that age in that position. A recorded check is not one that could detect a problem.
Staffing was short: the ratio fell well below the early years framework, and managers had a live feed of the room. The judge held that neither the ratio nor the cameras compelled or justified what happened.
What it teaches
In a baby room, restraint does not look like a hold. It looks like a position maintained by clothing and a soft surface, applied to a child who cannot resist, by an adult who believes she is settling her. The test is whether the child can move, turn her head and breathe.
A policy is only as good as the practice that proves it was followed. Individual and system failure are not rival explanations: the judge held the short ratio neither compelled nor excused the act.
Questions for the room
- Which babies in your room are settled in any position other than on their back on a firm, flat surface, and where is that agreed?
- Could your sleep-check records show a gap of ninety minutes, and who reads them?
- When a room is short-staffed, who can stop a shortcut such as a bean bag standing in for a cot?
Evidence and limits
Confidence: confirmed. The sentencing remarks and the BBC’s report, both of 22 May 2024, were read live on 7 November 2026. Greater Manchester Police’s release returns 403 to automated fetches; nothing here rests on it.
The baby is not named: the reporting names her and her parents, and this page uses role and setting. The nursery is withheld because reporting pairs it with her name. Kate Roughley is named because a jury convicted her.
No regulator determination appears in the sources read.
Our physical intervention training treats a position a child cannot leave as restraint, whatever the room is called.
Sources
- Courts and Tribunals Judiciary, 22 May 2024 · https://www.judiciary.uk/wp-content/uploads/2024/05/R-v-Roughley.Sentencing-Remarks.22.05.24.pdf
- BBC News, 22 May 2024 · https://www.bbc.com/news/uk-england-manchester-69048043
Reviewed 7 November 2026.