On 17th February 202 1 this Court commenced an investigation into the death of Toby Wilbur Barwick age 2 months (date of birth 24/11/2020). The investigation concluded at the end of the inquest held between the 23rd and 26th January :2023 . I arrived at a short form conclusion of open conclusion . The medical cause of death was determined following a post-mortem examination; 1 a Unascertained

Toby Barwick was born on 24th November 2020 at University College Hospital in London at 37 weeks gestation with a low birth weight of 2.1 kgs. On 12th February 2021 Toby's mother walked to her sister's home carrying her son at her chest in a fabric baby carrier device. On arrival at approximately 13.00hrs, Toby was sleeping. Mrs Barwick allowed Toby to nap in the carrier whilst she spoke to her sister, sitting on a sofa. Just before 14.15 Mrs Barwick found that her son was unresponsive, she shouted for help and removed him from the baby carrier. Emergency services were called and CPR was commenced. The ambulance service arrived and took over conduct of resuscitation , Toby was taken by ambulance to the local hospital. At hospital resuscitation continued until, at 15.43 doctors determined that continued action would be futile and Toby's death was declared.