Record of Investigation into Death (Withouth Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

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

‘Baby R’


Find That :

‘Baby R' died in October 2008 at her residence and was aged 3 weeks.

I find that ‘baby R’ died as a result of suffocation while co-sleeping with an adult.

Background Information

‘Baby R’ was born in the Royal Hobart Hospital (RHH) in October 2008.

From 1998 to 2007 the mother (‘Ms B’) was in a relationship with Mr S. This relationship was marked by intimidation and violence by Mr S. ‘Ms B’ regularly left Mr S as a result of Mr S's treatment. However she would return to the abusive relationship. Mr S has a significant criminal history of violence and drug offences. Since 2004 his record discloses three convictions for assault, including aggravated assault, for which he received suspended or actual prison sentences.

In both 2004 and 2005 police applied for restraint orders on behalf of ‘Ms B’ alleging acts of serious assault by Mr S. Whilst orders were made in favour of ‘Ms B’ for several months on each occasion, she was successful in having those orders ultimately revoked so as to be able to resume the relationship.

This relationship ended because of ongoing domestic violence.

‘Ms B’ has always lived with her children at several addresses with extended support from the Salvation Army, the Aboriginal Children’s Centre, the Children’s Centre and the Health Centre.

Before ‘baby R’s death, ‘Ms B’ had a criminal history including two drink driving offences, two convictions for assault, and a conviction for aggravated armed robbery.

‘Ms B’ and her children have been known to Child Protection Services since 2004 primarily due to allegations of family violence by Mr S and drug use by both ‘Ms B’ and Mr S.

‘Ms B’ has a past medical history of severe depression and alcohol and drug abuse. In 2005 Dr Barry Shaw commenced her on the anti-depressant, Prozac.

From 26 March 2008 to 1 August 2008 during her pregnancy with ‘baby R’, ‘Ms B’ served a period of imprisonment for aggravated armed robbery. On 4 August 2008, she attended Dr Richard Jackett. Dr Shaw, her regular general practitioner, was at that time on leave. On this occasion, Dr Jackett noted that ‘Ms B’ had recently been released from prison and was pregnant. She had been taking Prozac while in prison and had been stable on a dose of 40mg per day. He arranged a further prescription of Prozac for her.

On 30 September 2008 Ms Suzanne Drew, a Child and Family Health Nurse at the Department of Health and Human Services attended ‘Ms B’s’ address. ‘Ms B’ was at that time 38 weeks pregnant. They had a general conversation about her current family circumstances and who would care for her children during her admission to hospital to give birth. Ms Drew was aware that she was receiving ongoing support from the Salvation Army.

Ms Beverley Bradshaw, an Outreach Support Worker at the Salvation Army, states she has known ‘Ms B’ since about 1999 and has provided her and her children with ongoing support for 10 years. She is the godmother to one of her daughters. Ms Bradshaw arranged care for the children during ‘Ms B's’ period of imprisonment. Arrangement had also been made to extend her support during ‘Ms B’s’ forthcoming admission to hospital.

In October 2008 ‘baby R' was born in the Royal Hobart Hospital (RHH) by the Ventouse extraction method after 38 weeks and two days gestation. She weighed 2410 grams. She was diagnosed with non-specific respiratory distress and was treated using continuous positive airway pressure for 7 hours post delivery. The infant was further diagnosed with jaundice and was treated using phototherapy for 20 hours.

During ‘Ms B’s’ admission to hospital she participated in an assessment interview with Social Worker, Ms Tracey Turner. Ms Turner noted that the Salvation Army and friends were caring for 'Ms B’s' children in her absence. She noted that 'Ms B’s' two eldest children resided with their father’s family; and that Child Protection Services were not currently involved with any of the children.

'Ms B' stated to Ms Turner that she had abused drugs and alcohol during the early stages of pregnancy. She told Ms Turner that she would drink up to a carton of pre-mixed vodka cans per day. She said she ceased all illicit drugs during her period of incarceration and was taking prescription Prozac only. However, she told Ms Turner and also midwife Vicki Thomas that she continued to drink alcohol, up to a bottle of vodka every three days, until 2-3 weeks before 'baby R's' arrival.

Before giving birth to ‘baby R' ‘Ms B’ was accommodated in a unit supplied by the Hobart Women’s Shelter. However this agreement was due to expire on 30 October 2008. At this time she planned to seek private rental accommodation. 'Ms B' advised that her four youngest children would be residing with her. Thus 'Ms B' and her children were potentially close to a situation of homelessness.

'Ms B' outlined to Ms Turner that she had the assistance of multiple formal support agencies including the Salvation Army, the Hobart Women’s Shelter, the prison Chaplin, the Department of Health and Human Services, and the Aboriginal Health Service.

Ms Turner concluded that 'Ms B' had adequate involvement from a number of services in a monitoring and supportive capacity. Further involvement from the RHH was considered unnecessary unless new concerns were identified.

On 9 October 2008 ‘Ms B’s’ impending discharge was discussed with the Complex Care Midwife, Ms Vicki Thomas. Ms Thomas acknowledged the "risk factors" evident in ‘Ms B's’ situation. She considered however that ‘Ms B’ had substantial support mechanisms in place to monitor and provide a safety net. Ms Thomas had a subsequent conversation with Ms Bradshaw who, at that time, believed that ‘Ms B’s’ situation was currently stable.

At the time of ‘baby R’s’ birth a Child Protection Services worker, designated as "Royal Hobart Hospital liaison", assessed Ms ‘B's’ situation as not warranting further intervention based upon the community supports in place for her and her children, and the fact that there was no "unborn alert" in place for ‘baby R’.

‘Baby R’ was discharged from hospital in October 2008 with a scheduled review appointment with the Neonatal Discharge Co-ordinator on 13 October. According to the medical records from the Neonatal Intensive Care Unit at the RHH, she weighed 2252 grams and was feeding at discharge by breast only.

On 15 October 2008 staff at the Neonatal Unit at the RHH contacted Ms Drew to advise that ‘baby R’ had lost 26 grams. Her jaundice had returned and was marginally under the permissible level for mandatory treatment. ‘Ms B’ was advised to express milk to build up her milk supply.

On 16 October 2008 at 2pm, Ms Drew attended ‘Ms B’s’ residence. A breast feeding assessment established that ‘baby R’ had failed to gain weight in 3 days. She now weighed 2220 grams. ‘Ms B’s’ breast feeding patterns were considered to be within normal range. She continued to express to build up her milk supply. Ms Drew noted that members from the Salvation Army were also present and assisting ‘Ms B’ with home duties.

Ms Drew also discussed the issue of SIDS with ‘Ms B’ and provided her with both verbal advice and a pamphlet. Her verbal advice included:

  • placing ‘baby R’ on her back to sleep at the bottom of the bassinette;

  •  tucking in her bassinet blankets well;

  •  ensuring good air flow around her head;

  •  making sure she does not get too hot; and

  •  ensuring there is a smoke free environment.

Ms Drew did not specifically state to ‘Ms B’ that she should avoid sleeping with ‘baby R’ in her bed, particularly when other young children might also be in the bed. Such advice may have been desirable given ‘Ms B’s’ situation. However, Ms Drew’s advice emphasised the need to place ‘baby R’ in her own bassinet to sleep. Ms Drew was satisfied that ‘Ms B’ understood their conversation. A personal health record for ‘baby R’ was also supplied.

It should be noted that Ms Drew participates in a minimum of 8 training sessions per year on current information pertaining to SIDS and breastfeeding.

Ms Drew advised ‘Ms B’ to take iron supplementation for possible anaemia. ‘Ms B’ advised that she had made efforts to reduce her daily dosage of Prozac.

On 20 October 2008 Ms Drew was again contacted by staff at the Neonatal Unit at the RHH. She was advised on this occasion that ‘baby R’ now weighed 2188 grams. ‘Ms B’ was advised to supplement feeding with 2 x 30mls of formula.

During the morning of 22 October 2008 Ms Drew attended ‘Ms B's’ residence for her scheduled appointment. ‘Ms B’ was breastfeeding and using S26 Formula, 30 to 60 mls. ‘Baby R’ was noted to have gained 32 grams, her nappies were wet and there was improved urine output. These results were conveyed to the Neonatal Unit at the RHH.

On 29 October 2008, Ms Melanie Gibbon, Child and Family Health Nurse at the Department of Health and Human Services attended ‘Ms B’s’ address. She noted that ‘baby R’ now weighed 2440 grams and was feeding well. She was feeding 3 to 4 times a day with Formula and breastfeeding. She slept 3 to 4 hours at a time during the day. She was active and warmly dressed.

The house occupied by ‘Ms B’ and her children contained three bedrooms. ‘Ms B’ slept in one room with ‘baby R’s’ bassinet in the same room. Her eldest daughter slept on the couch in the lounge room due to the cold temperature of the rear bedroom. The third bedroom contained two sets of bunks occupied by the four other children. However, ‘Ms B's’ usual practice was to have one of her children sleeping with her.

Circumstances of ‘Baby R’s Death

During the evening of Thursday 30 October 2008, Ms B consumed two Jack Daniels drinks. At 11pm she breastfed ‘baby R’ in her bed. She had two of her children asleep in bed with her. According to ‘Ms B’, she breastfed ‘baby R’ on her right side, closest to the bassinette. During the feed ‘Ms B’ fell asleep. ‘Baby R’ fell out of bed and onto the wooden floor boards. She started crying. This woke Ms B and she picked ‘baby R’ up from the floor.

‘Ms B’ could not recall if she found ‘baby R’ facing up or down. Ms B cuddled her daughter on her left side in the crook of her arm. ‘Baby R’ was lying on her side. Her head was on the side of her mother’s left breast. She stopped crying. ‘Ms B’ then fell asleep.

Around 1am ‘Ms B’ woke to feed ‘baby R’, who was at that time still cradled on her left side. She went to the toilet and discovered blood on her singlet. Realising the blood was not coming from her, she checked on ‘baby R’ who was pale, limp and not breathing. She could see dry blood around her nose.

‘Ms B’ immediately woke her daughter, who had been asleep on the couch in the lounge room. Her daughter rang the ambulance. Ms B commenced CPR on ‘baby R’. The ambulance operator spoke to her daughter and relayed information on how to perform CPR to ‘Ms B’.

Two ambulance crews attended the residence at 1.15am and conducted a medical assessment of ‘baby R’. They found her apnoeic, cyanosed and in asystole. CPR was commenced using a bag and mask. They failed to gain intravenous and intraosseous access. She was transferred by ambulance to the Department of Emergency at the RHH.

On arrival at the RHH she was assessed by a resuscitation team. They found ‘baby R’ to be apnoeic, floppy and cyanosed. She had no cardiac output. She was in asystole. Blood was present in her mouth and nose and on her face. There was no evidence of obvious injuries.

Given the prolonged resuscitation time and her poor prognosis, all resuscitation efforts were ceased at 2.12am. ‘Baby R’ was declared deceased.

Medical personnel noted that 'Ms B' provided a contradictory sequence of events prior to ‘baby R’s death. She originally stated that ‘baby R’ was placed in her cot at 7.30pm on her back. The cot was beside her bed. She said she woke at 1.10am to find ‘baby R’ in her arms. She was cold, blue and not moving. She could see blood on her nightie. 'Ms B' stated that she noticed blood on ‘baby R’s' face. 'Ms B' appeared confused and said she was certain that she had placed ‘baby R’ in her cot. Shortly after giving that account 'Ms B' stated that she woke at 11pm to feed ‘baby R’ and placed ‘baby R’ into bed with her. She could remember ‘baby R’ then falling out of the bed.

A post-mortem examination was carried out by forensic pathologist, Dr Donald Ritchey. Dr Ritchey’s report incorporates these comments:

‘The autopsy revealed a well developed, small for age infant Caucasian girl with a 2cm subperiosteal haematoma on the parietal skull. There was no scalp contusion, no epidural or subdural collections of blood and there was no parenchymal brain injury. The subperiosteal haematoma is most consistent with residual bruising associated with the Ventouse extraction method utilised during ‘baby R’s’ delivery. Subperiosteal bruising of the skull vertex is commonly associated with this method of delivery and has no clinical significance when the contusion is small (as in 'baby R’s' case). There was no evidence of any significant trauma; specifically there was no evidence of ‘baby R’ having sustained any injury from falling from bed.

Toxicology testing of post mortem blood confirmed the presence of a "therapeutic concentration" of fluoxetine (Prozac) and caffeine. Therapeutic concentrations of drugs are reported in the medical literature for adults. There are no data regarding safe or toxic blood concentrations of fluoxetine (a selective serotonin reuptake inhibitor [SSRI] class antidepressant medication) in infants. The source of the medication is unknown although absorption of fluoxetine and caffeine via the gastrointestinal tract from mother’ breast milk is a likely explanation. Although the possibility of fluoxetine toxicity cannot be conclusively excluded as contributing to ‘baby R’s death’ it is my opinion that co-sleeping with an adult is the greater contributing factor.’

Dr Ritchey concluded that the cause of death was "unexpected death in infancy while co-sleeping with an adult". He states that this phrase is merely descriptive of the circumstances of death and allows for additional information to be considered as to the manner of death during an evolving coronial investigation without requiring a change in diagnosis or opinion.

I am satisfied that there was no intentional act on the part of ‘Ms B’ to bring about ‘baby R’s’ death. I am satisfied that the fall out of bed suffered by ‘baby R’ was accidental and caused by ‘Ms B’s’ inadvertence due to tiredness. ‘Ms B’ did not initially tell medical witnesses about ‘baby R’s’ fall. However, I am satisfied that this was only because she feared that she had harmed ‘baby R’ by not preventing her fall.

The ambulance officers noticed blood on ‘baby R’s’ face, mouth and nose, as well as her jumpsuit. They also noticed that ‘Ms B’ had blood on her top. Dr Ritchey is of the opinion that the presence of ‘baby R’s’ blood on ‘Ms B’ is consistent with ‘baby R’ being in very close proximity to her mother’s body at the time of her death. This also accords with ‘Ms B’s’ statements of ‘baby R’s’ position in the bed tucked into her left side.

I am satisfied on all of the evidence that ‘baby R’s’ face was in such close proximity to ‘Ms B’s’ body that she became unable to breathe. It is possible that Ms B unconsciously rolled onto ‘baby R’ whilst she was asleep. I cannot exclude the possibility that the adult bedding and the presence of the other two children in the bed also contributed to ‘baby R’s’ inability to breathe.

The alcohol consumed by ‘Ms B’ is likely to have played some part in Ms B's inability to rouse so as to ensure that ‘baby R’ was safe. There is insufficient evidence to allow me to determine the strength of the spirits she consumed. Two alcoholic drinks of the type described would, by themselves, have the potential to increase sedation.

In a previous finding, [2008] TASCD 187, relating to the deaths of four infants I set out the risk factors in relation to sudden unexpected death in infancy. The risk factors identified belonged to three categories - infant factors, parental factors, and environmental factors. Without repeating those comments, I find that ‘baby R’ was subject to a multiplicity of those risk factors. They are as follows:

  •  she was of low birth weight (less than 25

  •  ‘baby R’ was subject to some, albeit less serious, neo-natal health problems;

  • ‘Ms B’ did not have a supportive partner;

  • ‘baby R’ had multiple siblings, including a very young brother and sister;

  • 'Ms B' had short inter-pregnancy intervals;

  • alcohol and drug use by 'Ms B';

  • 'Ms B' was of low socio-economic status;

  • ‘baby R’ was sleeping on adult bedding;

  • ‘baby R’ was asleep in a side sleeping position;

  • ‘baby R’ was sharing a sleep surface with her mother and two siblings.

The prescription drug Fluoxetine (Prozac) was discovered in ‘baby R’s’ blood, having been passed to her through ‘Ms B's’ breast milk. Dr Ritchey advises that it is not ideal for the drug to be present in the system of an infant. The effects of the drug upon an infant are uncertain. However, I accept his opinion that the effects of Fluoxetine are unlikely to be a contributing cause of ‘baby R’s’ death.

I have investigated whether it was appropriate for ‘Ms B’ to be prescribed Fluoxetine during pregnancy and lactation. The drug is not contra-indicated in pregnancy in Australia. ‘Ms B’ had a significant history of depression which required treatment and she was stable on this medication. I am satisfied that it was appropriate for ‘Ms B’ to take Fluoxetine as prescribed.

I am satisfied that ‘Ms B’ was aware of the key aspects of safe sleeping. She had a separate bassinet for ‘baby R’ in her bedroom and was aware of the potential dangers of an infant sleeping with an adult, particularly when the adult has consumed alcohol or drugs. The safe sleeping messages had no doubt also been conveyed on the occasions of the other children's births. ‘Ms B’ was a loving mother to ‘baby R’, and did not intentionally disregard such advice. However, she had four other very young children in her sole care, suffered depression, and struggled with an alcohol and drug addiction. It is understandable that her overwhelming tiredness on occasions led her to sleep with ‘baby R’ instead of returning her to her bassinet. Ironically, such difficult personal circumstances require a particularly high degree of care to ensure that an infant does not sleep with an adult in the same bed.

I convey my sincere condolences to ‘Ms B’ for the tragic loss of ‘baby R’.

Child Protection Issues

There were many factors that indicated that ‘baby R’ was a child at risk of harm through ‘Ms B’ not being able to safely and adequately care for ‘baby R’. All of these factors were matters that were either known to Child Protection Services (CPS) or could, with little difficulty, have been discovered.

Before ‘baby R’s’ birth, the CPS files on each of Ms B's children were voluminous. There were multiple notifications on the family to CPS since 2005. These involved concerns that the children were at risk of harm or neglect due to ‘Ms B's’ drug and alcohol use and also being subject to family violence at the hands of Mr S.

On 26 March 2008 CPS received a notification that ‘Ms B’ was in custody and likely to be placed in remand, and that the children had been alone at home since the previous night with no protective adult present. The notifier indicated that ‘Ms B’ had been taken to hospital regarding a suspected miscarriage, although CPS records note that the risk of harm had passed. Thus it was at this stage that CPS were aware of a viable pregnancy and should have been on alert to a further birth in the family.

The notification of 26 March further states that the family is currently on the "unallocated list" and two priority notifications have been forwarded to assessment within the last two months. The author of the file note assessed the harm consequence to the children as "extreme" and the future risk as "high risk".

The CPS "unallocated list" requires brief explanation. Once the notification has been received by the intake team and an initial risk assessment has been completed, a decision is made, using the Tasmanian Risk Framework, as to whether the child or the allegations require further protective investigation. In the event that the intake team assess that the child is at risk and requires a protective investigation the matter is referred to the "response team". When a case is unallocated it means that it is awaiting allocation to a worker for a protective investigation to take place. Unfortunately, during the period leading to and just after the birth of ‘baby R’, CPS in the south of the State had a significant backlog of cases requiring an investigation. This backlog was referred to as the "unallocated list".

CPS was notified on 7 April 2008 about possible risk to the children following the arrest and remand of ‘Ms B’ for armed robbery. In the documentation, the Child Protection worker came to the conclusion that with the assistance of the Salvation Army and the Tasmanian Aboriginal Corporation (TAC) assisting with day care, there was "no current role for CPS". Child Protection workers were not able to find the children on this occasion and it appears no further investigation was undertaken in order to determine their whereabouts, who they were with in absence of their mother, or the level of support provided by the Salvation Army and other service providers.

On 21 July 2008 Child Protection Services received a notification regarding ‘Ms B's’ older child. . This related to a concern by police that ‘the child’ was homeless, in a relationship with an older man, and not attending school. A follow up by CPS on this matter confirmed that ‘Ms B ‘was pregnant. Contact by CPS was then made with the Royal Hobart Hospital Complex Care midwife who reported that ‘Ms B’ was presenting reasonably and receiving support from the Royal Hobart Hospital social work unit and the TAC. CPS requested that the RHH advise of the outcome of ‘Ms B’s’ assessment with the hospital social worker so that consideration could be given as to whether an unborn child alert was required.

CPS did not actively engage in further enquiries as to the level of risk to ‘Ms B's’ unborn child.

Whilst there was no unborn alert in place, the CPS liaison worker at the RHH nevertheless was aware of ‘baby R's’ birth and the general history of child protection notifications for the family. The CPS liaison worker accepted the social worker’s assessment and was satisfied on the strength of it that there were sufficient supports in place for Ms B and the family such as not to warrant CPS intervention.

There was no further intervention or investigation by CPS in respect of any of the children, including ‘baby R’, until after ‘baby R’s’ death.

The evidence indicates that CPS was inadequately equipped and resourced to properly deal with all of those notifications which had been assessed as requiring investigation. There was not sufficient staff or expertise to actively and fully investigate those matters on the unallocated list. It was an unacceptable situation for the vulnerable children involved, the CPS staff and the community as a whole. I accept that of the large number of children unallocated, there was no doubt differing degrees of risk and urgency relating to their protection.

In respect of all of ‘Ms B’s’ children there were obvious factors that placed them clearly at risk of harm or neglect, such that particular attention was required in preparation for ‘baby R’s’ birth, and that they no longer remain on the unallocated list. I have previously referred to those factors but will summarise them:

(a) ‘Ms B’s’ drug and alcohol dependence;
(b) ‘Ms B’s’ severe depressive illness and possible borderline personality disorder;
(c) her lengthy imprisonment for armed robbery whilst pregnant with ‘baby R’;
(d) her unstable accommodation situation and the family’s potential impending homelessness;
(e) the history of family violence;
(f) ‘Ms B’s’ lack of a supportive partner;
(g) the fact that ‘baby R’ was to be her seventh child;
(h) the number and content of notifications to CPS since 2005.

The most striking features of the inadequate CPS response to the above risk factors are as follows:

(a) the several opportunities by way of notifications before, and at the point of ‘baby R’s’ birth, that should have acted as important signals to allocate the matter for immediate investigation, including a fully informed decision as to whether an "unborn alert" was appropriate;

(b) the reliance without question by CPS officers upon persons in an "official" capacity assisting the family or purporting to assess risk to the family;

(c) a failure to appreciate the risk to ‘baby R’ by in light of the background of numerous and serious notifications in respect of the other children over a period of 4 years;

(d) the chronic lack of staff and resources that contributed to the family remaining on the unallocated list despite the serious nature of the risk.

With regard to the above, CPS made no independent assessment of the level of the supports that were purportedly in place for the family. It appears that no detailed discussions occurred with ‘Ms B’ about her ability to care for the children and about her mental health and substance abuse issues. There was no attempt to investigate exactly how much support was in place, apart from accepting the word of persons such as Ms Bradshaw, Ms Turner and Ms Thomas. Ms Turner and Ms Thomas appeared to base their assessments largely upon ‘Ms B’s’ word that she had sufficient support. They were not persons that had any longstanding knowledge of ‘Ms B’s' situation. Ms Bradshaw to the contrary had been very close to the family for a long time and may well have been reluctant to speak negatively of ‘Ms B’ or to concede the need for CPS involvement.

Importantly, there was no attempt to determine the degree of dependence by ‘Ms B’ upon alcohol and drugs. In sentencing ‘Ms B’ for the armed robbery charge on 1 August 2008 Justice Slicer commented as follows:

"When interviewed by police, ‘B’ admitted that she was the owner of the weapon and had asked S to take part in the crime. She admitted her part in the robbery, stating that she was in financial difficulties and had taken amphetamine shortly before entering the premises……

‘Ms B’ is aged 34. She has six children aged between 14 years and 20 months. She is again pregnant. She has had a difficult life. Some 12 months previous she had lived in an extremely violent relationship which had resulted in the removal of her at risk children by child protection officers. She has been a user of opiates since the age of 15. She has been the subject of episodic violence, both sexual and non-sexual. The Court accepts that at the time of the robbery she was under financial pressure, having the household domestic gas supply disconnected. She had been drinking heavily and was persuaded by the accomplice to take amphetamine shortly before the commission of the crime.

……She has suffered extreme violence at the hands of family when young, and also partners within her own relationships. She has had to seek refuge in safety homes to protect herself and her children. She suffers from episodic depression and has a history of substance abuse. Financially she is always on the edge, often because of the misuse of money by her partners. She has received some external assistance and, in the words of a supporting officer of the Salvation Army, "When she is travelling well she travels really well", and has periods of being stable and "provided well for her kids".

Bad relationships and substance abuse remain central to her dysfunction."

The full text of His Honour’s comments were published and available to CPS. However, CPS did not seek that information.

‘Ms B’s’ alcohol consumption particularly in the early stages of pregnancy was known to be at danger levels. Further, her ability to cope with her seventh child in light of her substance and mental health problems was not explored with medical professionals. Finally, it appears that CPS did not at any relevant stage speak to any of ‘Ms B’s’ children directly with a view to assessing the question of risk.

Given the lack of resources, there would have been an understandable temptation and some comfort in relying upon the advice of other persons and organisations that indicated ‘Ms B’ had sufficient support to properly care for all of her children. However the duty of CPS is non-delegable. If a more comprehensive investigation regarding risk had been undertaken as indicated I have little doubt that CPS would have ascertained that ‘baby R’ was a child at risk. I fully accept that a proper investigation would have been costly and time consuming. However, that was what was required in this case. Even if CPS had actively commenced a thorough investigation only upon ‘baby R’s birth it would have likely been ascertained that she slept regularly with both ‘baby R’ and son, contrary to safe sleeping guidelines, such that ‘baby R’ was at risk in this regard.

Notwithstanding my criticisms of the CPS approach, it is not appropriate to make comment about the actions of any particular employee of CPS. Those that I have spoken to for this investigation, and those involved with ‘Ms B’s’ family at the relevant time, appear to be diligent individuals and performing their role as best as they are able within a problematic and under-funded framework. The lack of resources for taking active steps to investigate families on the unallocated list was unfortunately a major factor informing decisions regarding questions of risk and appropriate intervention.

I am not able to make a positive finding that ‘baby R's’ death would not have occurred if CPS had acted in the manner I have described. It may have been that an appropriate outcome after thorough investigation would have seen ‘baby R’ remain with ‘Ms B’, but with very close monitoring pursuant to a court order or otherwise. In such a situation there would be no guarantee that ‘Ms B’ would not have taken ‘baby R’ to bed with her. However, her chance of survival would have been higher. CPS had significant powers to implement measures to supervise and assist the family; and to protect ‘baby R’ and reduce the risk of harm to her.

CPS has been helpful and forthcoming in the coronial investigation. I have been provided with the files for ‘Ms B’s’ children held by CPS and have met with three managers of CPS with knowledge of the files. Upon a review of their files they advise that there was not an adequate consideration of the "cumulative harm" principle, given the very long history of notifications. The process of simply receiving added notifications from time-to-time whilst unallocated was not conducive to considering the totality of the risk factors, and then making a decision as to risk based upon the history as a whole. Further, they acknowledge that too much reliance was placed upon conclusions by "official notifiers" when CPS should have independently examined and investigated the risk factors applicable to ‘Ms B’ and ‘baby R’.

I acknowledge that CPS are now actively involved with ‘Ms B’s’ children, including ‘her baby‘ born after ‘baby R’. Care and protection orders in respect of the children are currently in place.

I also acknowledge that from 2008 onwards there has been considerable reform of the child protection system. I have been provided with considerable written and oral information by CPS about such reforms. In particular, I accept that part of the reform is directed towards addressing the systemic shortcomings referred to in this finding. These reforms include:

(a) The introduction of regional intake teams. The Child Protection Intake team was previously managed on a statewide basis, with a large number of referrals. The staffing levels were inadequate, and decisions and action was slow as represented by the unallocated list. In the reform process there were created four separate regional intake teams with more active monitoring policies.

(b) In respect of each of the four regions specific "gateway" services have also been set up, operated by recognised community organisations. These gateway services, that each include a child protection worker, are designed to ensure that appropriate supports and interventions are provided to children at risk in a timely manner. Notifications are able to be made to each gateway service.

(c) A significant amount of government funding has been provided for three years to maintain the gateway services.

(d) An emphasis in the guidelines upon the concept of cumulative harm. Intake decisions must be based upon the entire history. Relevantly, if there are three notifications relating to the same matter, with no action proposed by the Child Protection worker, then such decision must proceed to a higher level.

(e) Formal role-specific training for Child Protection workers, rather than the previous informal "buddy system"; and online practice manual.

Importantly I note that currently there is in progress an inquiry by the House of Assembly Select Committee on Child Protection. This is a broad-ranging inquiry into the adequacy of Tasmania’s child protection systems. Relevantly the inquiry involves examination of early identification, intervention and prevention strategies currently in place within all relevant agencies, including the Department of Health & Human Services and Gateway service providers. It will also examine mechanisms currently in place, and where improvements can be made to enhance the integration between all relevant agencies to ensure that the welfare of any identified child at risk is paramount and that all agencies work together to provide best practice care and service delivery.

Conclusions and Recommendations

In summary my findings are as follows:

(a) that ‘baby R’ died by suffocation, accidentally occurring whilst she was sleeping in close proximity to her mother and siblings and amongst adult bedding;
(b) that it was contrary to safe sleeping guidelines for ‘baby R’ to be co-sleeping with her mother when Ms B had consumed alcohol before going to bed;
(c) that it was contrary to safe sleeping guidelines for ‘baby R’ to be sleeping amongst soft adult bedding and co-sleeping with siblings;
(d) that the drug Fluoxetine found in ‘baby R’s’ blood cannot be found to have played a part in her death;
(e) that the fall suffered by ‘baby R’ earlier in the evening cannot be found to have played a part in her death;
(f) that CPS should have fully and actively investigated the level of risk to ‘baby R’ before and/or upon her birth; and taken steps to protect her from the major risk factors referred to in this finding;
(g) The failure of CPS to actively investigate is largely explained by the existence of a large unallocated list and the unsatisfactory management of cases on it; this in turn is explained largely by a lack of funding to CPS at that time.

In 2008 I made comments and recommendations regarding the prevention of sudden infant deaths. I set out below my conclusions and recommendations contained in those findings:

"1 Despite a significant reduction in the rate of deaths attributable to the SIDS and Kids campaign, Tasmania still has an unacceptably high level of Sudden Infant Deaths.

2 Almost all of these deaths are preventable by elimination or reduction of risk factors.

3 The birth hospitals are diligent in developing their own policies and adopting safe sleeping practices. However, there is a need to determine whether staff members, across all hospitals in the State, are correctly and uniformly conveying safe sleeping practices.

4 There is a need for particular targeting and education of high risk sub-groups in the Tasmanian population, so that important messages for SIDS risk reduction become entrenched.

5 The message should be imparted repeatedly and correctly both antenatally and after discharge from hospital. This may involve wider publication and education of Safe Sleeping practices to schools and other organisations.

6 There is a need at least for government funding for a SIDS educator and/or project worker in the community to address some of the above issues and funding for further materials and resources in hospitals.

7 There is a need for consideration to be given to a fully co-ordinated government response to specifically devise and implement effective strategies to achieve a reduction in the high rate of SIDS deaths in Tasmania.

The deaths of the four infants concerning the subject of these findings were all associated with an unsafe sleeping environment. Two of the deaths involved bed sharing. Parents and infants derive comfort and enjoyment by sharing a bed for feeding or cuddling. However, 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."


  1. I recommend government and key stakeholder organisations give consideration to the issues and comments in this finding and give consideration to the development and implementation of strategies for the prevention of sudden infant deaths in Tasmania.

  2. Specifically, I recommend that the Department of Health & Human Services adopt a lead role in:

a. developing a single set of consistent guidelines that define the appropriate strategies to be implemented by parents, carers, and health professionals for the reduction of risk factors in sudden unexpected deaths of infants;

b. considering whether the Paediatric Mortality and Morbidity Sub-Committee of the Council of Obstetric and Paediatric Mortality and Morbidity should be responsible for drafting or advising on the guidelines, with continuing responsibility for drafting or advising on updates to the guidelines in accordance with current medical research;

c. publishing the guidelines amongst the medical and nursing professions in both the public and private sector;

d. publishing the guidelines in the wider community generally, including amongst current and future parents (eg. in antenatal classes and secondary schools);

e. conducting a SIDS education program statewide (perhaps by employing a SIDS educator), with particular reference to any high risk sub-groups;

f. implementing a requirement that all child health nurses/community nurses receive updated training about the guidelines, and;

g. ensuring that SIDS risk assessments are conducted with parents upon the mother’s discharge from hospital, with appropriate information about the guidelines provided to them."

I have, for the purposes of this finding, requested a response from the Department of Health and Human Services as to whether any of the recommendations have been considered. My request for this information was made on 3 September 2010 and acknowledged by the Department on 15 September 2010. However, I have not received any formal response since that time. I therefore am not aware of whether the Department has considered these recommendations.

Tasmanian Coordinator of SIDS and Kids, Ms Sharon Davis, has helpfully provided me with a detailed response regarding the extent to which she understands the recommendations have been implemented. I accept her analysis. Ms Davis indicates as follows:

  • that Hospitals have become more vigilant in making certain that staff are giving consistent messages regarding safe sleeping. The Launceston General Hospital has recently completed a survey showing 100% compliance by staff with the safe sleeping message. Additionally the hospital's antenatal classes include a session on safe sleeping practices;

  • that SIDS and Kids Tasmania has been working more closely and collaboratively with Child Health and Parenting Centres regarding training initiatives for those health professionals;

  • that easy to read brochures and posters for parents have been produced. These particularly target those with low literacy. SIDS and Kids Tasmania have dispatched these to all hospitals, child health centres and general practitioners throughout Tasmania.

The Department of Health & Human Services has not provided funding for a SIDS and Kids Educator. Ms Davis states that this is very disappointing as there is still much work to be done to reduce the rate of sudden infant deaths. An educator would be able work proactively in disseminating the message to all relevant avenues and to provide more training programs in faster time frames. The educator would also be able to develop "train the trainer" programs for training new health professionals entering the work force. The educator would also be responsible for information displays in shopping centres and schools to reinforce the correct message. Ms Davis states that it is very concerning that SIDS and Kids do not have the resources to implement strategies in respect of the teenage bracket, as it is at this age that the message should be initially absorbed. A funded educator would be able to focus upon this age bracket.

I commend the work of SIDS and Kids Tasmania in its continuing efforts to reduce preventable sudden infant deaths in this State. It is disappointing that the Department of Health & Human Services has not apparently taken initiatives to develop or fund a fully coordinated strategy for the prevention of infant deaths.

Tasmanian coronial records reveal that since the death of ‘baby R’, there has been 14 sudden deaths of infants under the age of one year in Tasmania. While some of these deaths have not yet been the subject of formal findings, it appears that a high proportion are associated with unsafe sleeping practices, particularly co-sleeping; as such they are preventable. My previous research disclosed that Tasmania has the second highest rate of sudden infant deaths after the Northern Territory.

I strongly urge the Department of Health & Human Services to consider my 2008 recommendations as a matter of high priority with the aim of preventing further deaths of infants due to unsafe sleeping practices.

I again urge the parents of infants under the age of 12 months not to sleep in the same bed with their infants, but to always place them on their back in their own cot to sleep.

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.

DATED : 2 December 2010 at Hobart in the State of Tasmania.

Olivia McTaggart