RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)

Coroners Act 1995
Coroners Rules 2006
Rule 11

These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of  Coroners Act 1995

I, Olivia McTaggart, Coroner, having investigated the death of

Baby A

WITHOUT HOLDING AN INQUEST

FIND THAT:

1. Baby A was born in Hobart on 29 July 2010 and died in Hobart on 20 November 2010, aged 3 months.

2. Baby A was the infant child of S and H.

3. I find that Baby A’s death is a sudden unexplained death in infancy in circumstances of co-sleeping with an adult and two siblings.

Baby A was born at the Royal Hobart Hospital on 29 July 2010, the third born of three daughters to S and H.  The two older daughters were born 17 December 2006, and 25 July 2008 respectively. 

S experienced a generally uneventful pregnancy. She stated that during the pregnancy she smoked on average six to seven filtered cigarettes daily. She also consumed one or two glasses of wine a week and was self-medicating with ‘over-the-counter’ codeine for headaches she regularly experienced. A codeine packet of 24 usually lasted about a fortnight but she indicated that her doctor was not aware of this issue.

Baby A was born just before midnight on 29 July 2010 following a short labour that preceded a natural birth process. At birth she weighed 2985g (6lb, 9½oz) and, though slightly small in size, she was deemed healthy and did not require any additional hospital care. 

Baby A passed all the required examinations and upon receiving her inoculations left for home with S on 31 July 2010.  An Extended Midwifery Service check, at the Royal Hobart Hospital the following day noted an overall weight drop of 245g on her birth weight but subsequently noted the following day that Baby A had recovered 130g of the loss and was breast feeding well.

Background:

S and H had a relationship for approximately six years during which they had three children, including Baby A, in less than four years.  H also had three children from a previous relationship. However these children did not live with them. 

During the latter part of the relationship S was prescribed anti-depressants by her doctor and she continued to use them throughout the pregnancy and after the birth of Baby A.  There were issues within the relationship and they are said to have separated and reunited on up to 10 occasions.  Shortly after Baby A was born, S and her children moved out of the family home and into an address in Lindisfarne. At this location she was closer to her parents and felt better supported by them as a single mother.

After a period of time S and H reconciled and he also moved into the Lindisfarne address.  The arguments between them continued and when police were called on 6 November, H was issued with a Police Family Violence Order which included conditions to “not stalk; and not directly or indirectly threaten, harass, abuse or assault” S.

On 17 November 2010, after another argument between them, police attended and H asked to be taken to Rokeby due to the conditions of the order.  H did not return to the home before the death of Baby A on 20 November 2010.

Baby A’s Health Issues:

On 17 August 2010, aged 19 days, Baby A was admitted to the Royal Hobart Hospital with mild bronchiolitis. She spent four days under observation and treatment in the Paediatric Intensive Care Unit, at times on assisted breathing procedures.

Hospital records for this period indicate there is no suggestion of any chronic illness; and in the opinion of the consultant paediatrician at that time her admission on this occasion was unrelated to her later death at age three months. 

On 9 September, at age 10 weeks, Baby A was taken to the family general practitioner Dr Hilary Bower with a rattly chest, blocked nose and cough. She was diagnosed with suffering a ‘viral illness and was mildly unwell’.

On 23 September she again presented with a rash and cold. The rash, while looking like sores, did not appear to concern her.  She was diagnosed with a ‘staph infection’.

On her return to the doctor on 1 October it was noted that while Baby A was well within herself the rash was worse and had spread all over her body.

Baby A presented again on 12 October and it was noted that the rash was worse. Again she was said to be sleeping and feeding well and appeared untroubled by the rash. The S sought a second opinion by taking Baby A to see another doctor.  On this occasion the rash was diagnosed as appearing to be bites.

On 4 November 2010, when Baby A again presented to the doctor with no improvement in the rash, she was referred to paediatrician Dr Ian Stewart with suspected ‘scabies’. S had also developed a slight similar rash on her abdomen; however Baby A’s siblings remained ‘rash-free’.

Dr Stewart’s diagnosis strongly suggested scabies. He provided advice to both Baby A and S, with an agreement to review Baby A in seven to 10 days. However Baby A died before this review could take place.

Circumstances Surrounding Baby A's Death:

On the morning of Friday 19 November 2010, S awoke around 6.15am. She had slept in the middle of her bed, sharing it with Baby A to her left and her second eldest daughter, aged 18 months, to her right. S’s eldest daughter, aged four years, had slept in her single bed which was to the left and adjacent to the main bed.

S prepared breakfast and readied both older children for child care, prior to them leaving around 8.15am when collected by their grandmother.  She then tried to feed Baby A, however she did not feed very well. S then placed her in her bassinette where she slept until around 11.30am. When Baby A woke she fed better, but again used only one breast and appeared to pull away towards the end of the feed. She is said to have still looked sleepy. 

S and Baby A then went to Eastands Shopping Centre between 12noon and 2.00pm to do the grocery shopping. Baby A was placed in the trolley but remained unsettled and fought off sleep.

On returning home S then walked to her parent’s address, 15 minutes away, with Baby A in a ‘baby front-pack’, arriving around 3.15pm. S was able to successfully feed Baby A and Baby A had a short sleep before they returned home around 5.30pm.

Her other children arrived home at about 6.00pm, had tea and changed into their pyjamas. At 7.00pm they all left to visit S’s grandmother, with S’s mother.  Baby A had to be awoken to be placed safely in the car for the short journey.  All returned home about 8.15pm.  S’s mother then left and they all went to bed.

S lay with her children until they went to sleep before getting into the bed herself, on the far left with Baby A between her and her sister. She was on the far right of the same bed. Before getting into bed S took three ‘over-the-counter’ codeine tablets as a glass of wine she had had at her grandmother’s house had given her a slight headache.  She claimed that she regularly used ‘over-the-counter’ codeine for headaches she experienced, the last remembered occasion being three tablets, two days earlier on Wednesday morning.

S woke at about 4.00am and breast-fed Baby A but stated that Baby A didn’t feed well, again using only one breast.  She then left the bed to get a drink of water. She was followed by her eldest daughter, who was upset at S leaving the room without her.  When they returned to the bedroom about three minutes later, S noted that Baby A had gone back to sleep.  She and her daughter got back into the bed and S went back to sleep.

S next woke around 6.00am when she became aware of her eldest daughter standing at her side of the bed.  She realised that Baby A was not beside her. She got out of bed, pulled back the doona to discover her lying on her back, in the lower half of the bed. She was on top of the blanket that she had previously been wrapped in and her head was towards the bottom of the bed.  She also noticed that Baby A was pale, unresponsive and appeared not to be breathing.  Leaving Baby A on the bed, S ran to the lounge room and called 000 on her mobile phone before returning to the bedroom. The Ambulance Tasmania operator gave her instructions on what to do and stayed on the phone to her until the ambulance arrived about 10 minutes later.

The attending ambulance staff immediately took Baby A to their vehicle where they attempted to resuscitate Baby A for about 15 minutes, without success.  Both S and Baby A, in the company of a police officer, were conveyed to the Royal Hobart Hospital by ambulance.  After being examined by medical staff Baby A was declared deceased.

Forensic Pathologist Dr Donald Ritchey conducted a full post mortem examination of Baby A on Monday 22 November 2010. He subsequently provided the Coroner with a detailed report of his investigations. Dr Ritchey concluded that Baby A’s death was an “unexpected death in infancy while co-sleeping with adult and siblings”. He stated that contributing circumstances were that Baby A was suffering ‘respiratory bronchiolitis, rhinovirus infection and scabies’ at the time of her death. I accept Dr Ritchey’s opinion regarding Baby A’s death.

Studies have shown that sharing a sleep surface with a baby increases the risk of sudden unexpected death in infancy. Additionally adult sleeping environments may contain hazards that can be fatal for babies including accidental overlaying of the baby by an adult or suffocation from pillows, blankets or bedding. Sharing a bed with an infant can be particularly unsafe if the parent is affected by drugs or alcohol.

The message promoted widely by SIDS and Kids Australia is not to sleep on the same surface as an infant.

Whilst the SIDS and Kids safe sleeping program has been very successful in reducing the rate of sudden unexpected deaths in Tasmania, these deaths comprise a high proportion of potentially preventable deaths of children under the age of 18 years.

In line with Dr Ritchey’s conclusions I cannot find that Baby A would have survived if she had slept in a cot of her own. Her cause of death, as opposed to the circumstances of death, cannot be ascertained. However, the fact that she was sleeping in the same bed as her S and her sisters with adult bedding was a significant risk factor in her death. It is possible that Baby A’s death may have been caused or contributed to by suffocation under the heavy bedding towards the foot of the bed where she was located by S in the morning.

S has stated that her other children also slept with her in her bed. She stated that she did not, in respect of any of her children, recall being advised against sharing her bed with her children. Whilst that is possibly the case, it is not necessary in this finding to investigate this point further. It suffices to say that S was in that category of vulnerable parents who would have benefitted by strong and regular reinforcement of safe sleeping practices. I further note that S did not use the Child Health and Parenting Service (CHAPS), which would have been one service that could have emphasised the importance of ensuring that Baby A slept in her own cot.

It should be noted that the family were known to Child Protection Services.  The risk issues to the children identified by that service (before Baby A’s birth) included alcohol use by S, exposure to family violence and S’s non-engagement with support services.  However when S was 4 months pregnant with baby A, Child Protection Services assessed the family as needing no further intervention and that S’s situation had improved. This was because S was engaging with her general practitioner, her mother was a strong source of support and she was not consuming alcohol. Child Protection Services also notified the social worker at the RHH, who assessed S’s situation after Baby A was born. At that assessment S again declined any referrals to relevant services for support, and stated that she had the support of her mother and grandmother. All information at that stage indicated that, whilst the family had some risk issues, S was caring well for her two older daughters, and would be able to appropriately care for A.

S was a loving caring mother to Baby A. I convey my sincere condolences to S, H and family members in respect of Baby A’s tragic and unexpected death.

General Comments:

As I have stated in previous findings, there is a particular ongoing need for targeting and educating high risk sub-groups in the Tasmanian population, so that important messages for risk reduction in sudden infant death become entrenched.

The Department of Health and Human Services (DHHS) has recently developed a “Safe Sleeping” DVD. The DVD is targeted towards those families who are most at risk of co-sleeping with their baby while under the influence of drugs or alcohol.  The DVD will be used as a tool primarily by Child Protection (including Gateway) staff, CHAPS staff and midwives to engage with parents in this high risk category. It is not intended that the DVD be used as a public education tool, but appropriately it is for use with a small cohort of parents under the guidance of professionals. The DVD has been endorsed by the SIDS and Kids organisation.

Having viewed the DVD, I am impressed by the way in which the message is conveyed. It is an excellent initiative that will be a powerful tool for professionals in emphasising to high risk parents the possible tragic consequences of sleeping with their infant whilst they are under the influence of alcohol or drugs.

DHHS is to be commended for the development of this DVD and for its associated strategy for communicating safe sleeping information to new parents. I encourage extensive dissemination of this DVD to appropriate professionals and monitoring to ensure that it is regularly used as an educational tool.

In previous findings I have recommended that the government provide funding for an additional SIDS and Kids employee, so that the education functions and much needed grief counselling function of that organisation could cope with statewide demand. Such a recommendation remains relevant.

There are, however, a number of ways in which existing services might enhance their education role in respect of infants at risk.

I have recently met with Angela McCrossen, Senior Quality and Practice Advisor Quality Improvement and Workforce Development with Children and Youth Services in respect of how Child Protection Services and other services might assist with education in safe sleeping practices.

The issues that I identified for discussion with Ms McCrossen were as follows:

• In cases identified through several coronial findings, the family and deceased child has been known to Child Protection Services but was not made subject to formal intervention as the family were well supported by both informal and formal supports.

• The non-intervention of Child Protection Services in these cases is deemed reasonable as the protective concerns are identified as appropriately managed. 

• Despite extensive and appropriate supports, some parents are continuing to engage in unsafe sleeping practices with their infants, in particular sharing the same sleep surface.

• The safe sleeping message was not always communicated clearly or regularly to this group of high risk families such that it had efficacy.

Ms McCrossen provided the following comments and suggestions in response to these issues:

• In the cases noted, it would be most appropriate for Child Health and Parenting or community supports to be in place to ensure that the messages around safe sleeping are embedded and communicated to families – particularly those who have been identified as vulnerable due to history of co-sleeping, presence of prescription drug use and alcohol consumption.

• There is currently a Model of Care review occurring within the Child Health and Parenting Service (CHAPS) which will focus on vulnerable families and children. The review is working to move the focus from a primary intervention to a secondary intervention (targeted support for those who need it).

• There is an emphasis on maintaining close and “linked-up” service provision between CHAPS and Child Protection for those children who have dual status or are deemed to be at increased risk.

• The risk assessment strategies and principles currently in use within Child Protection Services could be reviewed with the view to ensuring that the risk issues associated with co-sleeping are highlighted clearly and are well defined.  The Special Assessment Guide which is in place to support Child Protection staff to assess risks for infants could be reviewed to ensure this is the case.

• There will shortly be a Nurse Quality and Safety practitioner and a Nurse Educator employed within Children and Youth Services. These roles will be critical resources to provide additional support and guidance to Child Health and Parenting staff in order to enhance nurse education and practice. Findings and concerns identified through coronial reviews in regards to education and intervention around co-sleeping would be useful to embed into future nurse education and practice improvement strategies. These positions would be pivotal in doing so.

• Recent training has been provided to Child Protection Services staff in regards to safe sleeping practices in order that advice can be correctly imparted to families.

I have also sought information from acting CHAPS Manager, Raylene Cox. I set out below, absent footnotes, an extract from the report of Ms Cox, as it usefully describes the strategies and proposed measures to address the risk issues to vulnerable families. She states:

“The Child Health and Parenting Service is undergoing a review of the Model of Care. This review has 32 recommendations with many focusing on strategies to strengthen engagement of families identified as vulnerable, as well as looking at different ways to work with families from marginalised population groups. The Model of Care also asks CHAPS to review the number of universal contacts for families (currently 10) with a view to reduce, therefore allowing more clinical time to work with those families who are difficult to engage. Currently CHAPS has released a Concept Draft outlining how the service plans to deliver care to clients who will be assessed to receive one of three levels of care, depending on vulnerability.  …

 CHAPS delivers the SIDS message universally to clients who access the service at 2wk, 4wk, 8wk and 4 month Child Health Assessments. The service has been revising the Sleep/Settling protocol and this steps out what should be covered in the standard SIDS message at each of these contacts:

‘When discussing SIDS with parents (as per the PHR) five safe sleeping messages will be given (from SIDS and Kids):

1. Sleep baby on the back from birth (not on tummy or side);
2. Sleep baby with face uncovered (no doonas, pillows, lamb’s wool, bumpers or soft toys);
3. Avoid exposing babies to tobacco smoke (before or after birth);
4. Provide a safe sleeping environment (cot meeting Australian standards, firm mattress, safe bedding, avoid over-heating);
5. Sleep baby in their own safe sleep environment next to the parent’s bed for the first 6 to 12 months of life (i.e. in a cot, bassinet or other safe sleep surface).’

In addition, the safe sleep DVD is available for use by Child and Family Health Nurses and more copies have recently been received to distribute to all nurses. While the DVD is intended to be shown to families identified at risk, such as those babies that have an unborn alert through Child Protection Services, the Child and Family Health Nurses believe it has wider application. Nurses will be encouraged to show the DVD to families they identify as vulnerable and the new Model of Care will provide more opportunity for nurses to work differently with families that have previously been disengaged. It provides opportunities to work in partnership with other agencies to use assertive engagement strategies to help engage and work with vulnerable clients.

I have discussed your email with my colleague, Christine Long, who has carriage of sleep/settling matters state-wide for CHAPS. We agree we have effective strategies in place to ensure CHAPS receives information about all public and private hospital births and this means we have a high rate of initial contact. We also have sound mechanisms in place to convey key messages to clients who engage with CHAPS but our difficulty remains in reaching those who do not engage i.e. they may avoid all appointments, even home visits, or use the service once only.  As CHAPS is not a mandatory service, we will continue to persevere in trying to engage clients and one of the recommendations of the Model of Care relates to investigating possible incentives as a tool to retain clients.”

The positive responses received from both Ms McCrossen and Ms Cox demonstrate both willingness and commitment from Child Protection Services and CHAPS to assist vulnerable families in reducing the risk factors often present in cases of sudden infant death.

Infants under the age of one year remain the most vulnerable group of children to date.  Whilst much has been done to reduce the number of sudden unexpected deaths and SIDS deaths in Tasmania they still make up a high proportion of potentially preventable deaths of children under 18 years of age.

In this finding it is appropriate to make the following recommendations:

(a) In line with the SIDS and Kids recommendations, I would urge parents of infants to return the infant to his/her own cot before the parent goes to sleep, and to place the infant on its back for sleeping.  The heartbreak of losing an infant life in such circumstances has far reaching consequences for the family and for the community as a whole.

(b) That parents of infants make use of the home and clinic visits and advice provided by nurses from CHAPS.  This service is critical to ensuring that the messages around safe sleeping are embedded and communicated to families, particularly those who have been identified as vulnerable.

(c) That all health providers involved with the antenatal and postnatal care of infants take the opportunity, when appropriate, to impart correct safe sleeping practices to parents and those caring for the infant.

(d) That Child Protection Services and CHAPS continue to implement the positive strategies, as outlined in this finding, targeted to effectively identifying and educating vulnerable families in safe sleeping practices, incorporating use of the educational DVD and information sheet recently developed for this purpose. 


DATED: 28 June 2012 at Hobart in the State of Tasmania.


O M McTaggart
CORONER