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(c) of Coroners Act 1995 

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

Baby T


Find That :

Baby T died on or about March 2009 at Port Sorell.

Baby T was born at the North West Regional Hospital, Burnie and at the time of her death she was aged 2 weeks.

I find that Baby T died as a result of sudden unexpected death in infancy while co-sleeping with adults.

Circumstances Surrounding the Death :

Baby T was born February 2009, at the North West Regional Hospital in Burnie to Ms N and Mr H. Baby T had two elder siblings

Baby T was delivered normally with no complications. She was quite small in size, (2.9 kg). Baby T had a faulty heart valve at birth which corrected itself within 24 hours of being born. She had no other problems.

On Saturday 28 February 2009, the family travelled to Port Sorell to Mr H’s sister’s house to stay for a few days.

At about 9.30pm on Sunday 1 March, Ms N and Mr H retired for the evening after checking that all the children were sleeping. Baby T was sleeping in her capsule near the bedroom door whilst Ms N and Mr H were sleeping on a mattress on the bedroom.

At around 2.00am Ms N took baby T or into bed with her to feed her. She laid baby T on her arm to do so. After she finished feeding her baby Ms N placed her back into her capsule to sleep. Baby T was breathing at this time.

At about 5.00am baby T was again breast fed in the bed with her parents. After finishing feeding her this time baby T was placed between herself and Mr H. Ms N rubbed baby’s back to burp her and then they all fell asleep again.

When Ms N woke about 8:30am baby T was lying on her upper arm and shoulder area. She could not hear Baby T breathing. She jumped up and screamed out to Mr H "god she isn’t breathing".

Mr H got up, turned on a light and then took Baby T. Ms N ran to telephone an ambulance.

A member of the volunteer emergency response unit who lived nearby was the first response person to arrive, followed shortly by ambulance officers. They were unable to revive baby T.

Forensic Pathologist Dr Ritchey, upon post-mortem examination, was of the opinion that baby T died of ‘sudden unexpected death in infancy while co-sleeping with adults’.

Dr Ritchey states that:

the autopsy revealed a well developed, well nourished, apparently well-cared for, somewhat small for age infant girl with a healing fracture of the midshaft of the right clavicle and petechiae of the covering of the heart (visceral pericardium). There were no other injuries (acute or chronic) and there was no apparent gross or microscopic cause of death.

The healing fracture of the right clavicle probably represents birth trauma. Although a review of birth records does not indicate any birth difficulty; birth trauma is by far the most common cause of an isolated clavicle fracture in an infant. This fracture was healing at the time of death as evidence by callus formation (scar) seen radiographically, grossly and microscopically. These findings indicate that the fracture is at least as old as the infant (14 days); placing the probable time of fracture at birth

Subsequently, Dr Ritchey reviewed the evidence from the completed police investigation. He noted in his comments that Baby T had a broken collar bone, which resulted from birth trauma. He states that upon all the evidence he cannot determine whether baby Tor passed away through purely natural causes (SIDS), or whether she passed away due to her breathing being restricted by loose bedding or proximity to adult bodies. I accept the conclusions of Dr Ritchey.

Comments & Recommendations :

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 another person or suffocation from pillows blankets or loose bedding.

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. Tragically they are still occurring on a frequent basis.

Ms Ms N states that she was not told by any health professionals about the importance of not sleeping with her baby so as to reduce the risk of sudden infant death. Whether or not that is correct, it is clear that she did not appreciate the importance of having baby T sleeping on a separate sleep surface. She was a loving parent who was caring well for baby T. In line with Dr Ritchey’s conclusions I cannot find that baby T would not have died if she had slept in her own capsule. However, the fact that she was sleeping in the same bed as her parents was a significant risk factor in her death.

In previous findings since 2008 I have consistently noted that the advice not to sleep with an infant is not getting through to many people in the community.

In a recent inquest involving the death of an infant I heard uncontested evidence from Leanne Raven, the Chief Executive Officer of SIDS and Kids Australia. Ms Raven stated that it was well recognised that the safe sleeping recommendations for infants need to be imparted to any one parent on three separate occasions for them to be effective. If the advice is simply given on one occasion to a parent shortly after the birth of the child, it is unlikely to be fully absorbed; this is due to many other matters occupying the mind of a new parent.

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. 

I am not aware of whether the Department of Health and Human Services has considered my previous recommendations to assist with funding for an educator employed by SIDS and Kids. Ms Raven supports the need for such a position in Tasmania. 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 public areas and schools to reinforce the correct message. It is 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 excellent work of SIDS and Kids Tasmania, in its continuing efforts to reduce preventable sudden infant deaths in this State. The organisation has only one full time employee and a part time administrative assistant based in the North West of the State, to service all demands state wide for grief counselling, education and administration. I have no doubt that an additional educator would have a significant impact in lowering the rate of sudden infant deaths. I urge the Department of Health and Human Services to give consideration to this as a matter of priority.

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.

In concluding, I wish to convey my sincere condolences to the family of baby T for their loss. 

DATED : Monday, 18 of April 2011 at Hobart in the state of Tasmania.


Olivia McTaggart