Record of Investigation Into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Olivia McTaggart, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
Find That :
‘Baby J’ died in April 2009 at his residence in southern Tasmania and was aged 3 months.
I find that ‘Baby J’ died as a result of Sudden Infant Death Syndrome.
Circumstances Surrounding the Death :
‘Baby J’ was born in January 2009 at the Royal Hobart Hospital (RHH). His parents were ‘Ms R’ and ‘Mr L’. The pregnancy was without complication. ‘Ms R’ and ‘baby J’ left hospital two days after his birth birth. ‘Baby J’ was bottle fed from the time of his birth. He was a healthy baby apart from hypospadias which was to be corrected through surgery later in the year. He also had a cough which was present prior to him leaving the hospital.
‘Baby J’ was examined by Doctors Gianni Fantini and Miriam Tan of the Sorell Family Practice on five separate occasions between 23 January 2009 and 20 March 2009. During these examinations ‘baby J’ was noted to have a cough. During the medical examination with Doctor Tan on 4 February 2009, ‘baby J’s’ chest was noted to be clear. He did not display any symptoms of respiratory distress. Doctor Tan referred ‘baby J’ for a chest x-ray which was subsequently reported as normal.
Doctor Tan reviewed ‘baby J’ on 24 February 2009. On this occasion he was referred to the Paediatric Clinic at the RHH for review of his persistent cough. Doctor Tan noted that his chest was clear, but he coughed a little throughout the examination.
‘Baby J’ was diagnosed with a recurring viral illness at the Paediatric Clinic. A nasopharyngeal aspirate was obtained which later returned a negative result for influenza A, B and respiratory syncytial virus. A review appointment was scheduled for two months.
He received his two month immunisations on 10 March 2009.
On 20 March 2009 Doctor Fantini reviewed ‘baby J’ who was noted on this occasion as having a ‘wheezy/barking cough’. He was prescribed the antibiotic erythromycin. Doctor Fantini also performed a nasal swab to test for pertussis which subsequently returned as negative.
On Thursday 16 April 2009, ‘baby J’ was given a bottle and put to bed around 2pm for his afternoon sleep. He was wearing a cotton jumpsuit. He slept in a cot in his parent's room with a soft pillow and light baby blanket. ‘Ms R’; placed ‘baby J’ into his usual sleeping position on his right side with a rolled up blanket behind his back for support. He had a dummy. The house is a smoke free environment. He settled and went to sleep after approximately 10 minutes.
At 3.45pm ‘Ms R’checked on her son and he was lying on his stomach with his face down on the pillow. His baby blanket was on top of him and half way up his back. When ‘Ms R’ rolled ‘baby J’ over she could see that he was blue in colour and not breathing. She picked him up and immediately called out to her husband and his parents to assist.
‘Mr L.’ telephoned the ambulance. His mother ‘Mrs L took ‘baby J’ from ‘Ms R’ and commenced CPR until the arrival of ambulance personnel.
Ambulance personnel attended the residence at 4.02pm and immediately continued CPR with an oxygen supplement and suctioning of the airway. Their medical assessment determined that ‘baby J’ was in cardio respiratory arrest. He had no pulse and was not breathing. He had vomit in his airways. He was in asystole and his lips were cyanosed. His pupils were fixed and dilated and did not respond to light.
After failed attempts to gain intravenous access and given the prolonged resuscitation time and his poor prognosis, all resuscitation efforts were ceased at 4.18pm. ‘baby J’ was declared deceased.
Police were notified and attended the residence. ‘Baby J’ was later transferred to the Royal Hobart Hospital Mortuary by ambulance.
The circumstances surrounding the death of ‘baby J’ were investigated by Tasmania Police.
A post mortem examination was conducted by State Forensic Pathologist Dr Christopher Lawrence. He reported that the autopsy revealed no clear source of infection or obvious cause of death. He therefore concluded the cause of death to be Sudden Infant Death Syndrome. I accept his opinion.
‘Ms R.’ and ‘Mr L’ had taken thorough steps to ensure that ‘baby J’s’'s cough and wheeze was investigated and treated as far as possible. Yet ‘baby J’ remained with the virus. Research indicates that infants suffering from respiratory conditions are unfortunately at higher risk of SIDS.
I note also that the safe sleeping message promulgated by SIDS and Kids Australia is that an infant should be placed directly on its back to sleep, and not on its stomach or side. Research has shown that placing an infant on its stomach or side increases the risk of SIDS. ‘Ms R.’ and ‘Mr L.’s’ practice was to put ‘baby J’ to sleep on his side, believing that this was a safe sleeping position. Whilst this was not the recommended sleeping position I am not able to find that ‘baby J’ would not have died if he had been placed on his back to sleep.
‘Ms R’ and ‘Mr L’ were conscientious and loving parents. They have suffered a tragic loss of their baby. I convey to them my sincere condolences.
The Sudden Infant Death rate in Tasmania remains high. The safe sleeping message disseminated by SIDS and Kids requires further reinforcement. The basic principles of safe sleeping accepted and promoted by SIDS and Kids are as follows:
1 Put baby on his/her back to sleep from birth. Do not sleep baby on its tummy or its side.
2 Parents should not smoke before or after the birth of the baby.
3 Sleep baby with face uncovered. There are two ways to achieve this. Place baby’s feet to the foot of the cot, use only lightweight blankets, and tuck them in securely. Alternatively, a sleeping bag can be used without bedding. A safe infant sleeping bag is made in such a way that a baby cannot slip inside the bag and become completely covered. The sleeping bag should be the correct size for the baby with a fitted neck, armholes but no hood. Do not put a hat on baby to sleep.
4 Have a safe cot, safe mattress, safe bedding and safe sleeping environment for baby day and night. In this regard it is recommended that the cot should meet Australian Standards. Keep quilts, doonas, duvets, pillows and cot bumpers and fluffy toys out of the cot. Babies should not be left to sleep on tri-pillows or U shaped pillows due to the risk of suffocation. Prevent the baby overheating by ensuring that his/her head and face is always uncovered and by avoiding over heated rooms. Always dress baby appropriately for the room temperature.
5 Do not sleep with the baby on any sleep surface (bed or sofa). There appears to be no increased risk of SIDS or fatal sleep accidents whilst sharing a sleep surface with baby whilst feeding, cuddling and playing, providing baby is returned to his/her own sleeping environment before the parent goes to sleep. As indicated, the risks of sharing a sleep surface include overlaying of the baby by another person, entrapment or wedging and suffocation from pillows and blankets.
6 It is preferable to sleep baby in its own cot next to the parent’s bed for the first six to twelve months of life as this has been shown to be protective.
If the above practices are adopted with an infant, the chance of Sudden Infant Death is reduced. I urge all new parents to become familiar with these principles by thoroughly reading and placing in a prominent position the safe sleeping brochure produced by SIDS and Kids. The brochure is distributed to them on the birth of their baby and visiting Child Health nurses.
The visiting Child Health nurses now have good consistent procedures in place to advise new parents of safe sleeping practices upon home visits. However, given the obvious need for repeated reinforcement of the message, I would urge Child Health nurses to be particularly vigilant and to repeat the message where they perceive the presence of risk factors.
In 2008 I made recommendations in a finding regarding four infant deaths. In that finding I recommended that the Department of Health and Human Services take a lead role in a coordinated approach to reducing the incidence of sudden infant death in Tasmania. I made detailed recommendations as to what could be considered in relation to steps to prevent further deaths. One of those recommendations was the funding for a full-time SIDS educator.
On 3 September 2010 I wrote to the Department of Health and Human Services asking for a response to those recommendations. I have received no detailed response as to whether those recommendations have been considered. My enquiries with SIDS and Kids Tasmania reveal that they have not been implemented.
In its 2008 Annual Report released in October 2010, the Council of Paediatric Mortality and Morbidity reported on the sudden infant deaths occurring in 2008. It noted that all five deaths were associated with risk factors. In particular, all infants had been co-sleeping with adults. In respect of sudden infant deaths the Council made the following recommendations in its report:
"1. In view of equivalent numbers of cases reported as Unexplained Infant Deaths in 2008 compared to 2007, the issue of safe sleeping practices continues to remain an important issue for the Tasmanian community and the universal distribution of educational material concerning safe sleeping practices would benefit all new parents.
2. It is recommended that parental toxicology screening for those parents of infants with suspected drug association should be carefully considered in reported cases of Unexplained Infant Deaths. In particular, prescription of highly sedating drugs to adults who are primary carers of infants/children should be carefully considered by practitioners."
Since the beginning of 2008 alone, 15 Tasmanian infants under the age of 12 months have died suddenly. It appears that in a high proportion of this number preventable risk factors have been present. Such factors include co-sleeping with an adult, incorrect infant sleeping position and bedding and parental drug or alcohol sedation. I again urge that the Department of Health and Human Services consider implementing as a matter of priority a strategy to reduce the incidence of sudden infant death.
I would encourage this simple but extremely important message to be disseminated repeatedly by involved government agencies, health professionals, and the media whenever it is appropriate. The evidence reveals that repeated reinforcement is necessary to be effective in preventing the tragic deaths of infants in our community.
I would particularly urge consideration be given by government to the screening of television advertisements conveying basic safe sleeping for infants. Having the message conveyed orally and in pictorial form to a wide demographic may well be an effective way to instil correct safe sleeping practices, and therefore save the lives of infants in our community.
DATED : Tuesday, 7 December 2010 at Hobart in the State of Tasmania.