RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
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
WITHOUT HOLDING AN INQUEST
1. Baby H was born in Hobart on 20 August 2010 and died in Hobart on 1 February 2011, aged 5 months.
2. Baby H was the second child born to Ms M and Mr M.
3. I determine Baby H’s death to be consistent with Sudden Infant Death Syndrome (SIDS).
Baby H is the second child of Ms M and Mr M. At the time of her birth Ms M was aged 27 years and Mr M was aged 29 years.
Baby H was born at Hobart’s Calvary Hospital on 20 August 2010 at 38.1 weeks gestation. Ms M had an uncomplicated pregnancy. Baby H was delivered by the natural birth process after a spontaneous onset of labour; she weighed a healthy 3570 grams (7lb, 14 oz). Upon discharge with her mother she was breast feeding well and other than being slightly jaundiced there were no other concerns for her health.
Baby H did not develop any regular sleep pattern other than usually sleeping after each feed for differing lengths of time. From about four weeks of age she generally slept throughout the night. She would sleep in a suit and was wrapped in a blanket overnight, depending on the room temperature. She slept on a ‘mat’ that would set off an alarm if she stopped breathing and the room temperature was monitored as one of the functions of an electronic baby monitor. From about three months Baby H was able to roll over onto her stomach and soon had developed enough upper body strength to lift herself up when lying in this position.
Baby H developed a slight cold at age two weeks but after medical advice she was allowed to recover without medication. She also developed a ‘nasal’ sound to her breathing but examination of her nasal passages rarely indicated mucus.
By her six week check she had commenced bottle feeding with S26 GOLD formula, was noted to be ‘thriving’ and had increased her weight to 4170 grams. Baby H suffered severe reflux and frequent vomiting when feeding. On the advice of her treating paediatrician, the formula was changed to S26 ARA. A slight squint was also noted and a sight check was recommended if this did not correct itself after 3 months.
The change in formula initially eased her reflux but did not appear to alleviate her vomiting. At around 3 months of age, on the advice of the local pharmacist, Baby H’s formula was again changed, this time to S26SOY. This was due to the possibility that she was experiencing problems with the dairy content of the previous formula, similar to those that her elder sister had experienced.
At around four months Baby H was having five 180ml bottles a day and was commenced on processed baby foods and home-prepared mashed vegetables. She is said to have still suffered reflux however the amount of vomit regurgitated reduced. The advice of Baby H’s general practitioner was that she would ‘grow out of it’ as she otherwise seemed happy and healthy.
About this time she was moved to sleeping solely in the cot, still using blanket(s) if necessary but without a pillow. She began to roll around the cot and would sometimes roll onto her stomach. Occasionally she would require assistance to roll back onto her back.
Both Ms M and Mr M were provided advice and documentation in relation to the recommended safe sleeping practices aimed at SIDS prevention, as they had been for the birth of their first child.
CIRCUMSTANCES SURROUNDING BABY H’S DEATH:
On 31 January 2011, the day before her death, Mr M and Ms M took Baby B to the Greenpoint Medical Centre as she had developed a cough. Upon examination he was advised that she had a slight infection in her nasal passage, with the mucus irritating her throat and causing her to cough. As she was otherwise happy and healthy he was advised to use a saline solution and nasal aspiration but if the conditioned worsened to return.
Later that day Ms M took Baby H to a mother’s group meeting where she played happily on the floor. After a period of time she became tired and agitated so Ms M returned home with her and, after giving her a bottle, put her to bed for a sleep. That evening, after waking, she was fed a meal of mashed vegetables before being put to bed about 8pm. At this time she was also given 1.5ml of Nurofen.
The following morning, 1 February 2011, Baby H woke at about 6.45am. She was bottle-fed and then laid on the floor in front of the television, appearing fine and happy. Shortly afterwards she went to sleep. Ms M had planned during the day to go to the hospital to see a friend in the maternity ward. Not wanting to take Baby H to the hospital due to her cold she arranged with her mother, Ms B to look after Baby H for a couple of hours.
At about 9.30am Ms M arrived with Baby H at her mother’s house at 2 Bedford Street in Brighton. She advised her mother that Baby H was due for her next bottle feed at about 11am. Ms M placed Baby H in a bouncinette and left for the hospital.
Baby H was in view of Ms B while she moved around the house. At around 10.30am Baby H became agitated and so Ms B decided to feed her the bottle. Baby H did not feed easily but eventually drank the contents, believed to be around 240mls she was mildly distressed during her feed. Ms B stated that she “vomited a few times”. After burping Baby H and checking her nappy was dry Ms B wrapped her in a bunny rug and placed her in a porta-cot in her bedroom for a sleep.
Ms B placed Baby H on her back with her head on a thin adult-size pillow. A light blanket was placed over her, secured under the thin mattress at the foot of the cot, but not on either side. The room was darkened and Baby H was left with her dummy in her mouth when Ms B left the room.
After about ten minutes Ms B stated that she heard Baby H cry “a couple of times”. However she did not check on her as she did not wish to disturb her while she was going to asleep. After about a further ten minutes she quietly entered the room and noticed that Baby H was lying on her stomach across the cot, still wrapped in her bunny rug with her arm at her side. The cot blanket was not on her. Ms B also noticed that there was vomit around her mouth and when she turned her over to wipe it away she realised that Baby H was not breathing.
Ms B immediately placed Baby H on her own bed and checked her pulse. Feeling nothing she commenced CPR. Ms B hurried to the lounge room where she rang 000 and was guided by the operator with her CPR until the ambulance personnel arrived. Baby H was examined and found to be unresponsive and without a heart beat.
Police arrived shortly after and provided an escort for Baby H, in the ambulance under emergency conditions, to the Accident and Emergency Department of the Royal Hobart Hospital. CPR was continued en route and her colour was observed to improve. However she did not regain a heart beat.
Upon arrival at the Royal Hobart Hospital at 11.52am, Baby H’s care was handed to staff under the direction of Dr Kippax, the Emergency Department Staff Specialist. Staff assisting Dr Kippax included another emergency specialist, a paediatric intensivist, several senior emergency and paediatric registrars, a large number of senior emergency nursing staff and ancillary healthcare support staff. Sadly all efforts to revive Baby H were unsuccessful and resuscitative efforts ceased at 12.05pm. Baby H was pronounced deceased.
A post mortem examination of Baby H was conducted by Forensic Pathologist, Dr Donald Ritchey. In consideration of the details of the forensic autopsy and information available after police examined the scene from where she was taken to hospital Dr Ritchey determined Baby H’s death to be consistent with sudden infant death syndrome. This is defined as;
“the sudden and unexpected death of an infant under one year of age, with the onset of the lethal episode apparently occurring during sleep, that remains unexplained after a thorough investigation including the performance of a complete autopsy and review of the circumstances of death and the clinical history”
Dr Ritchey subsequently reviewed the complete evidence in the investigation into Baby H’s death. After that further review his opinion remained unaltered. I accept the opinion of Dr Ritchey and find that Baby H’s death is attributable to sudden infant death syndrome.
COMMENTS AND RECOMMENDATIONS:-
Ms M and Mr M were loving and diligent parents who provided Baby H with the best care possible. They were familiar with safe sleeping practices. Ms B was a devoted grandmother.
In previous findings I have made detailed comments upon the known risk factors in the sudden deaths of infants. In some cases of sudden infant death many risk factors, such as co-sleeping with adults and incorrect infant sleeping position, are present. In Baby H’s case there were few.
It is nevertheless appropriate in this finding to make comment about some factors that may possibly have been involved in Baby H’s death.
Baby H was correctly laid on her back to sleep. However, she was found lying on her stomach. I find that at some stage Baby H turned herself to lie on her stomach. She was able to roll over. It may be that her position on her stomach impeded her ability to breathe.
One factor identified on the evidence was the loose bedding comprising blankets and an adult sized pillow. Over many years epidemiologic studies have shown that babies who sleep amongst soft bedding are more likely to die of SIDS than babies that sleep on a firm surface with minimal covering. Thus experts recommend that soft objects including toys, loose bedding, adult pillows and pillow-like bumpers should not be used in the baby’s sleep area. These things contribute to an unsafe sleeping environment which is one risk factor for SIDS but not an independent cause of death.
I strongly emphasise that I am not able to find that Baby H would not have died if her cot bedding was as recommended.
During her pregnancy Ms M continued to smoke cigarettes, although at a reduced rate compared to before her pregnancy. After Baby H was born she would not smoke in the house or around her. Smoking during pregnancy is known as one factor that may contribute to SIDS deaths.
There was copious vomit on the bedding and aspiration was identified microscopically within Baby H’s lungs. Dr Ritchey stated in hs advice to me that “based on the microscopic appearance of foreign material in the lungs I do not believe “aspiration” (of the vomit) is an adequate explanation for this child’s death; thus SIDS.”
Dr Ritchey further remarked that:
“70% of infants whose deaths are reported as SIDS have had upper respiratory symptoms (colds) prior to death. It is not possible to know if this reflects an actual contribution of a respiratory virus to death or simply the high prevalence of colds in infants.
The Triple Risk Model proposed in 1994 is the favoured model for “understanding” SIDS. It emphasizes the interaction of MULTIPLE FACTORS in the aetiology of SIDS. Accordingly SIDS occurs when three factors are present simultaneously:
A vulnerable infant (unknown genetic factors are likely).
A critical developmental period (immaturity of the brainstem and respiratory centres of the brain, prematurity, others).
Exogenous stressor (unsafe sleeping environments, extremes of temperature, colds or other mild infections, co-sleeping with an adult).”
By definition a child death classified as SIDS does not have a known cause of death. It is not possible to weigh the various factors in any one case in order to say that, “in this particular case the size of the pillow would make it a specific contributing factor” etcetera. The unfortunate truth is that linear “cause and effect” thinking fails us in our understanding of these cases because “causes” are multiple and in a given case undefinable.
I adopt Dr Ritchey’s reasoning and reinforce that is is simply not possible to say what was the cause of Baby H’s death nor the part played, if any, by any factors referred to above.
Whilst noting the complexity associated with the cause(s) of SIDS, I urge all prospective parents, parents and those caring for very young infants to be aware of the risk factors associated with SIDS and to try and eliminate those factors as best as they are able.
I convey my sincere condolences to Ms M, Mr M and family members for the tragic and unexpected loss of Baby H.
DATED: 14th February 2012 at Hobart in the State of Tasmania.