Record of Investigation into Death (WITH INQUEST)

Coroners Act 1995
Coroners Rules 2006
Rule 11 
I, Olivia McTaggart, Coroner, having investigated the death of
Lennox Paul CHAPMAN
BY AN INQUEST HELD in Launceston and Burnie in Tasmania on 4, 11-15 October 2010 and 28 February 2011 and 1-3 March 2011, and 4-5 April 2011, find as follows.


Lennox Chapman was born on 15 October 2008. He died on 2 December 2008. He was an infant aged 48 days at the date of his death.

The mother of Lennox is Katrina Louise Chapman, now Katrina Louise Gregory. During the inquest Ms Gregory was referred to as "Ms Chapman". It is therefore appropriate to use her former surname of "Chapman" throughout this finding.

The father of Lennox is Geoffrey Wayne Chapman.

At the inquest Mr Simon Brown appeared as Counsel assisting the Coroner.

Mr Stephen Wright appeared as Counsel for Ms Chapman.

Mr Wright also appeared as Counsel for Ms Chapman’s mother, Andrea Pisano.

Mr Andrew McKee appeared as Counsel for the State of Tasmania. Specifically he appeared for the Department of Health and Human Services, which provided treatment and assistance, through various services, to Ms Chapman.

Mr Chapman represented himself at the inquest.

The inquest was held to investigate the death of Lennox to enable me to make findings, if possible, pursuant to the requirements in s28 of the Coroners Act 1995. The particular focus of the evidence at inquest was in relation to s28(1)(b), (c) and (d), being how death occurred, the cause of death, and when and where death occurred.

Overview of important evidence

In order to understand the circumstances surrounding Lennox’s death I set out below an overview of the most relevant evidence under four headings. It represents the factual setting for the required findings. This evidence was plentiful and largely unchallenged, therefore easily allowing me to narrate these facts without the need for findings of credit. Where more detailed discussion pertaining to particular evidence is required I have set out reasons for my findings.

(a) Background

Katrina Chapman was born on 24 February 1978.

The evidence indicates that she was wilful as a teenager. In her later teenage years she became addicted to cannabis and Mersyndol, and suffered bulimia. Mersyndol is an analgesic medication available without prescription from pharmacies. It contains doxylamine (an antihistamine with calmative effects) combined with paracetamol and codeine (analgesics).

Ms Chapman was forthcoming at inquest about her long term history of heavy cannabis and substance abuse. She also described in detail her longstanding symptoms of bulimia. She described the pattern of hearing voices telling her that she was "fat" and/or "worthless", and then needing to vomit in response. She did not disclose hearing those voices to persons treating her at the time for fear she would be thought "crazy".

Despite the comments that I will make about Ms Chapman’s evidence at inquest, I accept her evidence of her past drug taking history and bulimia. It was consistent, candidly given and did not have the artificial quality that was present in her evidence on other matters. I accept that she did hear voices as she describes that were associated with her bulimia. Apart from the hearing of voices the medical witnesses indicated that Ms Chapman’s difficulties are well documented.

Ms Chapman was admitted on at least one occasion to the Spencer Clinic at about the age of 18 years due to mental health difficulties. The Spencer Clinic is a psychiatric inpatient unit located within the North West Regional Hospital in Burnie.

Shortly after this admission Ms Chapman left Tasmania to live in Western Australia. She remained there for about 3 years. I accept Mrs Pisano’s evidence that her mental health worsened whilst living in Western Australia, most likely due to increased levels of drug taking.

Despite her continuing high levels of cannabis and Mersyndol use, and her ongoing bulimia, she sustained long term employment at the Wivenhoe Milk Bar until the birth of Lennox.

Through her employment she made good friends, several of who gave evidence at the inquest. Those friends stated variously that Ms Chapman was a "happy", "bubbly" and "energetic" person, who took great pride in her appearance and was immaculately groomed.

In 2003 Ms Chapman met Mr Chapman.

In 2007 Ms Chapman and Mr Chapman were married and wanted to start a family immediately.

Unfortunately Ms Chapman suffered a miscarriage, which she attributed to her drug use and bulimia. Her pregnancy with Lennox followed shortly afterwards.

Whilst she was happy to be pregnant she was plagued by anxiety and obsessional thoughts that her baby would be stillborn or born with abnormalities or retardation. She spoke of such fears constantly to Mr Chapman. She did not talk of her fears to her mother or friends, who spoke of her being happy and radiant in pregnancy.

Her pregnancy was without complication. However, it appears that she attended more doctors’ appointments and sought more tests than usual during a normal pregnancy in a bid to assuage her anxiety. Despite medical reassurance she remained very anxious.

I accept her evidence corroborated by Mr Chapman that during pregnancy she significantly reduced her intake of marijuana from 6-8 joints per day to about 2 joints. I accept also that she reduced her Mersyndol intake from quantities as high as 25-40 tablets per day. I am sceptical though of her claim that she reduced her consumption to 3 or 4 tablets daily. She remained bulimic during pregnancy.

 (b) From the birth of Lennox until his death

Lennox’s birth on 15 October 2008 was uneventful. Ms Chapman was admitted to the North-West Regional Hospital the day before his birth and discharged several days later.

Lennox was born a healthy baby. However he was born with an abnormality of the cartilage of the ears. This was described as "drop ear" because it gave Lennox’s ears the appearance of being turned down at the top. This was a minor condition and self correcting. Whilst noticeable it did not particularly affect his appearance. He was a lovely looking baby. It did not affect his hearing and did not signify in his case any other abnormality.

Considerable medical difficulties for Ms Chapman followed the birth. Retention of the products of conception (being the placenta) caused Ms Chapman to become septicaemic and therefore very unwell. Two operative procedures were carried out within four weeks of Lennox’s birth to remove the placenta. The first of these was not wholly successful and Ms Chapman remained extremely unwell. The second procedure was required to fully remove the placenta.

Therefore Ms Chapman’s physical health was significantly compromised after the birth of Lennox. The evidence of Ms Chapman in this regard is amply corroborated by Mr Chapman’s evidence and the medical evidence tendered at the inquest. She remained physically unwell at the time of Lennox’s death. Being septicaemic she suffered fever, fatigue and general illness from the infection. I am not able to find that the illness caused delirium. However, it significantly exacerbated her pre-existing mental disturbance, reduced her ability to care for Lennox, and disrupted the usual bonding process between mother and child.

Ms Chapman’s mental health was poor following Lennox’s birth.

Her obsessive thoughts that Lennox was not normal did not dissipate upon his birth. Her irrational state of mind became entrenched, driven by the appearance of his ears. She was constantly reassured by doctors and family that Lennox was a normal healthy baby. However Ms Chapman became convinced that her baby’s ears were a sign of Downs Syndrome and she would spend time on the internet searching for links between his ear abnormality and other physical and mental abnormalities. Mrs Pisano’s emotional evidence about the extent of her daughter’s obsession is corroborated by the evidence of Mr Chapman and professionals providing treatment and support. The following passages of her evidence indicate Ms Chapman inability to bond and to cope:

"… She was crying all the time, saying she couldn’t cope, there was something wrong with him; she’s sure he had Downs Syndrome and it was all her fault … Because of the marijuana."

"All she was on about was his ears; that she’d been on the internet, that she was convinced there was something wrong with him, he’s probably got Down (sic) Syndrome. I just could not convince her – and he’s not responding and that she was really excited just before he died because he had made a little giggle and then she was in the lounge trying to make him giggle – yeah, it was – yeah. It was terrible."

Mrs Pisano also described the unusually remote and robotic manner in which Ms Chapman interacted with Lennox.

On 27 October 2008 Mrs Pisano became so concerned about her daughter that she called psychologist, Bernadette Smith, and related her daughter’s symptoms. Ms Smith formed the view upon that information, and what she already knew of Ms Chapman’s history, that urgent psychiatric input was required. She made an appointment for Ms Chapman to attend her practice on 31 October but Ms Chapman did not keep the appointment.

On 10 November 2008 Mrs Pisano again telephoned Ms Smith and said her daughter was in a "bad state". However, by that stage Ms Chapman was scheduled to see her general practitioner the following day. I note that Ms Smith did not commence treating Ms Chapman until after Lennox’s death.

On 11 November 2008 Dr Douglas Dow saw Ms Chapman in place of her normal general practitioner, Dr Ian Wild. Dr Dow saw Ms Chapman on something of an emergency basis. He was considerably concerned as to her mental health status and referred her to psychiatrist, Dr Ross Kirkman, and wrote to him regarding her situation.

When Dr Dow saw Ms Chapman, Lennox was then 4 weeks old. Dr Dow felt that she was in a "depressed, flat state". She was reporting an inability to sleep, placental retention and bleeding after her first post-birth curette. In evidence Dr Dow stated:

"I think the main thing that was somewhat disturbing to me, was that she could not bear to go near the baby or touch the baby and was anxious and breathless when she was near the baby.

She felt anxious when she was near it or (sic), and sounded like she was hyperventilating because of the anxiety."

Dr Dow prescribed Serepax at 30mg to be taken at night and to repeat it in 4-6 hours if she did not sleep - those to be given under the supervision of her husband. She was taken to see Dr Dow by her mother.

At the consultation Dr Dow noted that Ms Chapman was apparently bulimic and was also smoking and using cannabis; this caused Ms Chapman considerable anxiety and guilt regarding the possible harm she may have done to her infant son during pregnancy. Nevertheless, he noted that Lennox was apparently "doing quite well under the care of his father".

Dr Dow reported all of the above observations in his urgent referral letter to Dr Kirkman dated 11 November 2008.

An appointment was made for Ms Chapman to see Dr Kirkman on 18 November 2008.

On 11 November 2008, after Ms Chapman’s consultation with Dr Dow, she suffered an episode of extreme anxiety and required a home attendance by personnel from the Community Mental Health Team. The Community Mental Health Team (part of the Department of Health and Human Services) was at that time located at the Parkside mental health facility in Burnie. The Community Mental Health Team had an intake officer on roster and available to make home visits to persons suffering a mental health crisis.

On 11 November Mrs Judy Joyce was the intake officer. Her position was clinical nurse specialist. She is a very experienced psychiatric nurse. Although the intake officer would normally visit alone, Mrs Joyce was accompanied on this occasion by psychiatric registrar, Dr Bijou Thomas. Her extreme anxiety was precipitated by a large clump of hair falling out of Lennox’s head. Dr Thomas and Mrs Joyce spent about an hour with Ms Chapman and Mr Chapman. They formed the view that she was possibly suffering from an "acute psychotic episode post-partum". This was a provisional diagnosis only but based upon all symptoms exhibited by Ms Chapman, including delusional ideas. Admission to Spencer Clinic was discussed but rejected by Ms Chapman. Ms Chapman was provided with medication.

Mrs Joyce stated in evidence:

"We did make particular efforts to sort of say that she couldn’t at that time be left to look after the baby. Because she wasn’t capable of caring for the baby. And that it was in the best interests of the baby to have another responsible adult to tend to its needs. And we were, we were assured at that time that there would be family members that would be able to give support."

Mrs Joyce gave evidence of the thorough steps taken by the Community Mental Health Team over the following week to monitor Ms Chapman’s condition and try to link her with appropriate services and supports. Such follow up occurred until 20 November. On that date Mrs Joyce spoke to Ms Chapman who stated she had seen Dr Kirkman. Given that (a) Ms Chapman had stabilised; (b) Dr Kirkman had planned another weekly visit for Ms Chapman, and (c) the Child Health Nurse was to increase visits, the Community Mental Health Team decided it was appropriate to cease active involvement with Ms Chapman.

When Dr Kirkman first saw Ms Chapman on 18 November 2008 he prescribed her Olanzapine. Ms Chapman reported to Dr Kirkman that she had become pregnant but was anxious and worried about her ongoing use of Mersyndol, cannabis and her bulimia and that these feelings persisted through her pregnancy. Ms Chapman reported that Lennox had an ear abnormality and that she saw this as a sign of some other abnormality and Lennox was destined to have "mental problems" as an adult. Ms Chapman reported that she believed she had "damaged" Lennox. She also advised Dr Kirkman of her medical difficulties following the birth.

The assessment by Dr Kirkman was that Ms Chapman had had untreated bulimia and poly-substance abuse since her late adolescence with a history of dysfunctional relationships with both her parents. He reported Ms Chapman as having a fragile sense of self and saw herself as flawed and bad. He reported that she had been damaging her body for the last 17 years and now believes that through her own problems she had damaged her baby son. She believed that Lennox would be mentally unwell as an adult as she was.

Ms Chapman next saw Dr Kirkman on 24 November 2008 by which time she had herself stopped taking Olanzapine as she believed it made her feel worse. On 24 November 2008 Dr Kirkman reported in a letter to Dr Ian Wild that Ms Chapman was convinced that something was wrong with Lennox and that she had been on the internet diagnosing him with illnesses such as Downs Syndrome etc. He reported "she has totally unhelpful, negative, catastrophic ways of thinking and needs to engage in individual CBT (cognitive behavioural therapy). He commenced her on Fluvoxamine 50mg at night with a review in one week.

I note that through the period 29 October 2008 until the death of Lennox on 2 December 2008 Ms Chapman and Lennox received 6 home visits from Lennox’s health nurse, Heather Rose. The last of such visits being on 28 November 2008.

On about 30 November 2008 Mrs Beverly Chapman, Ms Chapman’s mother-in-law, visited her and described an incident whereby Ms Chapman acted very roughly and with anger towards Lennox. Such an incident exemplifies her troubled mental state and lack of ability to cope or relate normally to Lennox.

Mrs Chapman recounted that on that occasion Ms Chapman had told her that she had had "a bad night". She reported that Ms Chapman was "not well", "drawn" and generally dishevelled. She said "I’ve never seen anyone like that before". She described Ms Chapman as having "reefed" Lennox out of his chair "like a rag doll". She described Ms Chapman’s face, upon dealing with Lennox on that occasion, as "snarling". She recalled Ms Chapman heavily dropping Lennox onto his change table and described her as "ripping" Lennox’s nappy off. Immediately thereafter, Ms Chapman again raised the issue of Lennox being "subnormal".

The evidence of Mrs Beverly Chapman in this regard should be accepted. Her demeanour in giving evidence was impressive. She was a caring grandmother. She showed no artifice in recounting that incident. She clearly took no joy in recounting it and became significantly distressed when describing that episode. The manner in which she gave that evidence was in no way consistent with somebody who was taking any pleasure whatsoever in being critical or negative towards her former daughter-in-law.

Further, the evidence that she gave is in a general sense corroborated by other evidence from Mr Chapman and indeed Ms Chapman herself as to how Ms Chapman was dealing with Lennox and dealing with her family through the period of Lennox’s life.

It is of note that, when asked about that incident, Ms Chapman did not deny that it had happened.

Dr Kirkman again saw Ms Chapman on 1 December 2008. At that time Ms Chapman was reported to be in a similar mental state, although feeling a little less anxious at the end of the day when Geoff got home. She was avoidant of going out to the shops or seeing friends. Dr Kirkman believed that on Ms Chapman’s mental state examination that Ms Chapman showed some mood improvement and her affect was somewhat lighter. Her thought form was described as normal but also noted that the content of her thoughts included catastrophic worries about having damaged Lennox. He described no psychotic symptoms at that time and reported that Ms Chapman had insight that she was worrying excessively.

On 1 December 2008 Dr Kirkman continued her on the Fluvoxamine 100mg at night and commenced her on Quetiapine 100mg at night and 25gm by day "if not too sedated".

Dr Kirkman gave evidence as to why he prescribed that medication. Quetiapine is an anti-psychotic. However, in low doses it is efficacious medication for those suffering from acute anxiety. It is apparent that Ms Chapman was so suffering.

A side effect of this medication, for those unused to it or those who take an usually high dose, is a rapid drop in blood pressure upon positional changes (i.e. a feeling of being somewhat faint upon standing or changing position etc).

The medication prescribed by Dr Kirkman was collected from the pharmacy on 1 December 2008 on the afternoon of that day.

Dr Kirkman was significantly concerned about Ms Chapman’s mental health at this time. His initial visit with her was for perhaps an hour and his subsequent visits prior to Lennox’s death were between 15 – 30 minutes as opposed to a normal 15 minute visit. Whilst he considered that Ms Chapman was showing some depressive signs he believed that her major problem was anxiety. He did not diagnose her as suffering from any form of psychosis. He prescribed Quetiapine because Benzodiazepines were contraindicated with Ms Chapman’s drug addiction history, as was Valium. Quetiapine is non-addictive.

The possibility of an admission to a psychiatric unit was discussed by Dr Kirkman with the parents prior to 1 December 2008. However, that did not take place because both Ms Chapman and Mr Chapman were adamantly opposed to such an admission. Indeed, Dr Kirkman had a recollection of Mr Chapman commenting that Ms Chapman would be admitted to Spencer Clinic "over my dead body".

I emphasise that at all times before Lennox died Mr Chapman categorically rejected any suggestion of an admission for Ms Chapman to the Spencer Clinic. He said in evidence at inquest "I’d given Katrina my word, and I was not letting her go. Wasn’t happening". Ms Chapman herself said in evidence "I’d told Geoff that I never, ever wanted to go back to Spencer, and he promised me that he wouldn’t let me or Lennox go anywhere".

Dr Kirkman did not pursue an involuntary admission. It was his view that Lennox was being adequately cared for, that he was seeing Ms Chapman on a weekly basis, and she was being medicated for her anxiety. In short, Dr Kirkman felt "I can work with the situation, they were attending their appointments and Lennox was being adequately cared for and I thought "Well I will just have to work with the situation at hand".

It was Dr Kirkman’s view that Mr Chapman was supportive of Ms Chapman and the baby and that he was clearly engaged with Ms Chapman and him regarding her treatment. He further noted that Mr Chapman was "very, very clear, was at pains to try and clarify anything and I felt really that Geoff was the person who was best able to make sure that, you know, she understood what medications were for and so on… he was a good back up for her".

It was Dr Kirkman’s view that whilst an admission may have been the best and fastest way to improve her situation he did not feel that it was the only option open to him.

Importantly, a significant disadvantage of an admission to the Spencer Clinic was that it would mean that Ms Chapman would be separated from her child. Dr Kirkman felt that such a separation would not particularly assist Ms Chapman. Dr Kirkman also gave evidence that he recalled suggesting that Ms Chapman and child could be admitted to the "Mother and Baby Unit" in Hobart but this meant that Ms Chapman and baby would need to be separated from the family in Burnie. That option was also rejected.

Interestingly, Dr Kirkman noted that the suggestion of an admission to the Mother and Baby Unit in Hobart is frequently met with that response on the north-west coast; the complaint being that the unit is too far away, involves separation from family, and it is disruptive to travel so far. Further, many people do not have private health insurance.

Whilst Dr Kirkman gained a full and relevant history from Ms Chapman allowing him to treat her appropriately, he was not told by Ms Chapman, for the reasons discussed, of her hearing voices and also seeing Lennox’s face either constantly or occasionally distorted.

The extent to which Ms Chapman’s reporting of hearing voices and seeing Lennox’s face in a distorted way is the subject of considerable conjecture. I am reluctant to accept Ms Chapman’s own hindsight reporting of the vast extent to which she had heard voices. It is likely to be somewhat exaggerated in her evidence to the inquest for exculpatory effect.

However, there is credible evidence from Mrs Pisano that, during Lennox’s life, Ms Chapman saw Lennox’s face changing or distorting, such that he did not look like an infant. Such visions were contemporaneously reported to Mrs Pisano. The manner in which Mrs Pisano gave that evidence and her demeanour during that passage of evidence was consistent with someone who had no doubt that what they were being told was true. She was visibly distressed in giving this evidence. She was extremely pained by the recollection. I accept that Ms Chapman was contemporaneously reporting her serious concerns to her mother, distressed that she could not see Lennox as he really was. There was no reason for her to invent such a vivid image whilst Lennox was alive.

Dr Kirkman’s stated in evidence that if he had received a history of Ms Chapman hearing voices and seeing her baby’s face distorting before her eyes this would have been evidence of post-partum psychosis. I accept that on the appointment of 1 December he specifically asked about psychotic symptoms. They were denied by Ms Chapman, consistent with her longstanding resolve to not disclose them.

Dr Kirkman was of the view that the presence of these symptoms would render the danger to Ms Chapman and Lennox "significantly higher". He gave reasons why, in these circumstances, he would have pursued an involuntary admission under the Mental Health Act despite the strong protestations of Mr Chapman. He stated that in his profession he was accustomed to doing so despite objections from family. It is always difficult to gauge the accuracy of evidence given about past actions with the benefit of hindsight. In this case a treating specialist in Dr Kirkman’s position would have reasons for rationalising the matter in this way. His patient’s child died in her care when potentially he had the ability to secure her safety and that of the child. Nevertheless, I do accept his evidence that he would have sought an involuntary admission had he known about Ms Chapman’s psychotic symptoms.

Dr Kirkman gave lengthy evidence to the inquest. His evidence was given on two occasions. His treatment and opinions were appropriately the subject of searching examination by Mr Brown. He was the only treating psychiatrist giving evidence. He treated Ms Chapman extensively after the death of Lennox. He impressed me as a thorough, knowledgeable and dedicated treating specialist. His notes of attendances were written carefully in typed form at each consultation. His evidence was not in any significant way contradicted or diminished by other expert evidence. I will comment upon Dr Kirkman’s evidence throughout this finding in particular aspects.

The inquest had the benefit of expert evidence from Professor Paul Mullen, forensic psychiatrist. Professor Mullen, upon reviewing the evidence, formed the opinion that all care, treatment decisions, and prescription or medication provided to Ms Chapman by Dr Kirkman were "appropriate to the situation and of a good standard". 

(c) The day of Lennox’s death: 2 December 2008

At about 9.30am on 2 December Mr Chapman left the house to go to work. He was the proprietor of a tattooist business in Burnie.

Since the birth of Lennox Mr Chapman had been the main carer for Lennox and Ms Chapman. The evidence overwhelmingly indicated that he was an excellent father who adored Lennox. He was patient and supportive of Ms Chapman. He attended her medical appointments and ensured that he understood her treatment needs. He desperately wished for his wife’s recovery.

Whilst he was needed at home, the family was struggling financially without Mr Chapman’s income. A decision was made to leave Ms Chapman to care for Lennox by herself. He intended to work for only part of the day, from about 10am until about 2pm. He believed that his wife would manage as he thought her condition was improving. Mrs Pisano also knew of this decision, and was in the habit of telephoning her daughter daily from her own place of work.

I will discuss the events of this day further in this finding. As will be noted, there are significant difficulties in accepting the evidence or account given by Ms Chapman as to what happened while she was alone with Lennox at home.

I set out in the form of a brief chronology the events that can be verified by credible or objective evidence:

9.30am Mr Chapman left the house to go to work.

11.00am Mrs Pisano telephoned Ms Chapman to check all was well. Ms Chapman said she was very tired and was going to have a sleep when Lennox did.

2:12pm (approx) Ms Chapman telephoned Mr Chapman at his tattooist shop. She reported that she had found Lennox in his cot and that he was blue, and had blood coming out of his nose. She was advised by Mr Chapman to ring the ambulance and that Mr Chapman would come home.

2:13:00pm (approx) A call to ambulance was made by Mr Chapman’s work colleague advising of the situation.

2:13:46 Ms Chapman telephoned the Tasmanian Ambulance Service on 000 and commences a discussion with Senior Communications Officer, Nicholas Bradford . She advised Mr Bradford that she had found Lennox in his cot, cold, blue with blood coming out of his mouth.

2:14:31 Mr Bradford heard a baby crying.

2:15:20 The ambulance was dispatched.

2:15:26 Mr Bradford heard another baby’s cry.

2:15:28 Mr Bradford heard another baby’s cry.

2:25:00 Mr Chapman arrived home and found Lennox cold, pale and not breathing.

2:31:48 The first ambulance crew arrived at the scene and found Lennox not to be breathing and to have no pulse.

2:33:27 The 000 call is terminated.

2:40:00 Lennox was placed into the ambulance.

3:05pm The ambulance arrived at North West Regional Hospital.

3:28:00 Lennox was declared deceased.

For reasons set out further into this finding:

(i) I am satisfied that the cries heard by Mr Bradford were the cries (or more accurately vocalisations) of Lennox, who was alive and breathing at that time.

(ii) I am satisfied based upon the unchallenged expert evidence of Forensic Pathologist Professor Roger Byard and Paediatrician Dr Terry Donald who gave reports and sworn evidence to the inquest, that an external event occurring between the time Lennox is last heard to cry and the arrival of Mr Chapman was the cause of Lennox’s death. 

(d) Events subsequent to Lennox’s death

In the days after Lennox’s death Ms Chapman changed her account of how Lennox died.

On 6 December 2008, in the presence of Mr Chapman, his parents, her own father and family friend Adam Bax she stated; "I’ve got a confession to make. I killed my baby". Andrew and Frank Pisano also arrived. She then told the family that Lennox had in fact been in bed with her and that she had awoken and found herself covering or half covering Lennox; and he was cold, blue, not breathing and with blood coming from his mouth. She said that she had not told this story initially because she was scared of losing everything essentially because Lennox’s death was her fault.

On 6 December 2008 Ms Chapman also spoke for the first time of an incident whereby she accidentally dropped Lennox in the bath before he died, although she said that Lennox was not affected by it. Mr Chapman gives the following evidence about Ms Chapman speaking of the bath incident:

"… What she – she wanted to know when she was getting Lennox’s body back from the Coroner so we could have a funeral for him and if they’re gonna find anything that happened ‘cause she mentioned once that she dropped him in the bath and they’re gonna find something, that she dropped him in the bath and then she’s gonna be in trouble– it just kept going on, the same about dropping Lennox –

… And that they’re going to find something in his lungs or they’re going to come and get her and take her away or whatever they’re going to do."

Mr Chapman said that Ms Chapman was repeatedly recounting the bath incident at this time, as well as giving interchangeable versions of finding Lennox in his cot deceased and accidentally overlaying him.

There was also evidence from Beverley Chapman that on the day that Ms Chapman advised the extended family that her initial version (that she found Lennox in his cot not breathing) was not true and that Lennox had died whilst co-sleeping with her and that the death was "her fault", she overheard a conversation whereby Mrs Pisano was heard to say to Ms Chapman "We have to get our stories straight, otherwise you’ll go to jail for 22 years".

That conversation was also referred to in like terms by Mr Chapman when he gave evidence.

When Mrs Pisano was questioned in evidence she described those reports as "absolute rot".

However, I note that there is evidence from the family of other statements by Ms Chapman at around this time of changing her account, repeatedly said she said she feared she would go to jail.

I find that Mrs Pisano is likely to be in error in stating she did not make the remark. In my view Mrs Pisano’s denial of that conversation should not be viewed as a dishonest denial. The evidence of Mrs Pisano generally ought be accepted as being honest and given as truthfully as she could.

In terms of what was occurring at the family home on the day of the conversation in issue it must be remembered that Mrs Pisano had herself lost a grandchild suddenly only days before. She was very distressed herself at that time. She obviously loved Lennox dearly. She was also witnessing her own child having lost a child. For any mother that situation would be difficult to endure. Therefore, in the light of the fact that she gave evidence of other conversations at around this time which involved discussions involving "jail" I think it likely that the evidence of Mr Chapman and Beverley Chapman about a remark along the lines that they gave evidence about to have been broadly correct.

However, whilst there was a deal of contention about whether the maternal grandmother made that remark, there is no evidence of what Ms Chapman herself actually said to prompt such a remark. It is plain that on the day in question Ms Chapman was saying that she "killed" her child and that Lennox’s death was her fault. She was therefore making distressing but generalised admissions to having harmed her child. No doubt those types of remarks would be distressing for Mrs Pisano in all the circumstances who might well have been trying to frighten her daughter out of making such dramatic statements tending to falsely incriminate herself.

To Mrs Chapman and Mr Chapman hearing that statement (or something similar) it might have seemed as though Mrs Pisano was acting in collusion with her daughter to cover up facts to which they were not privy. However, there is no evidence whatsoever that Mrs Pisano had any superior knowledge of the circumstances of Lennox’s death; and she certainly was not a witness to it.

On 8 December Ms Chapman made a brief statutory declaration to police for the coronial investigation stating that she was sleeping with Lennox when he died.

From then on, Ms Chapman’s psychological state deteriorated dramatically.

In the months that followed she gave several others a third account of Lennox’s death; that being that she had intentionally killed him by smothering him. She variously reported to her mother, Mrs Chapman, her psychologist and her psychiatrist, Dr Kirkman, that she had intrusive memories, recollections or visions of herself having intentionally harmed Lennox by strangling him or covering his mouth with her hand or covering his face with a pillow or cushion. I will deal with these as they arise in chronological sequence.

On 9 December Ms Chapman was admitted to the Spencer Clinic in the North West Regional Hospital after disclosure to the family that she planned to commit suicide. There was no resistance from Mr Chapman to this admission.

Mrs Pisano was present with a doctor when Ms Chapman was admitted. Ms Chapman then gave a different account of Lennox’s death in the following terms stating:

"I had Lennox in the bed with me and I’ve smothered him. I woke up and he was blue and I had my hand on his face..."

I accept Mrs Pisano’s evidence of this statement. It is not necessarily a clear admission by Ms Chapman to a deliberate act but it represented the start of a series of statements made about smothering Lennox with her hand.

On 22 December Ms Chapman was discharged from the Spencer Clinic.

On 27 December she attended the hospital emergency department with psychotic symptoms.

From 8 January until 12 February 2009 she was an inpatient at the Spencer Clinic.

From 12 February 2009 until 3 April 2009 Ms Chapman was an inpatient at Rivendell Clinic, a mental health facility attached to the North West Private Hospital.

In April 2009 Mr and Ms Chapman separated.

On 30 June 2009 Mr Chapman was interviewed by police and advised that Ms Chapman had, over a recent weekend they had spent together stated to him that she had smothered Lennox intentionally.

Mr Chapman told police of this account. In his evidence in court he repeated the account given by Ms Chapman:

"…That she took him to bed, she couldn’t cope with the way her life was, she took him to bed, put her hand over his mouth and nose and just held it there and when she was doing this all she kept saying was: "His little eyes kept staring at me saying, ‘What are you doing Mummy?’ " And as soon as that come out of her mouth, by this stage we were sitting at the kitchen table in my house, ‘cause once she said she had things to tell me I got out of bed and made her go and sit at the kitchen table. We were sitting at the kitchen table when she told me that she had smothered him with her hand and his little eyes kept staring at her saying, "What are you doing Mummy?"

It is appropriate at this stage to make comment upon Mr Chapman’s credibility as a witness. I was most impressed with Mr Chapman’s consistently clear and concise answers to questions. He was unguarded to the extent of openly blaming himself for leaving the house to go to work on the day Lennox died. His evidence was intelligent, rational and honest. It was not clouded by prejudgment of people or situations. Because of the admission made by Ms Chapman to him, Mr Chapman may have suspected that she acted deliberately. However, his presence at the inquest was calm and thoughtful. He asked only relevant questions of witnesses and displayed no hostility to Ms Chapman. In fact at points in his evidence he recalled her with affection, despite their separation. Whilst I was carefully scrutinised Mr Chapman’s assertions for accuracy, on many occasions’ aspects of his evidence were proved correct by other independent evidence. The one area of his evidence that did not exhibit these positive qualities was that involving Mrs Pisano. He asserted dogmatically that Mrs Pisano had an unhelpful influence over her daughter and made other assertions that were not supported by the evidence or indeed the character of Mrs Pisano as shown by her evidence at inquest on two separate days. The main explanation for Mr Chapman’s somewhat biased view of Mrs Pisano lies in the negative information that Ms Chapman had regularly conveyed about her mother to Mr Chapman. This quite calculated process of undermining may have been a symptom of Ms Chapman’s borderline personality disorder, according to psychologist Bernadette Smith when she gave evidence. In any event the aspect of Mr Chapman’s evidence to which I refer to reflects more upon Ms Chapman’s ability to manipulate situations for her own immediate purposes rather than any inherent lack of credibility on Mr Chapman’s part. For these reasons I accept the evidence of Mr Chapman. There will be further discussion about specific aspects of his evidence.

On 23 September 2009, 10 months after Lennox’s death, Ms Chapman was formally interviewed by police. The version that she gave to police was essentially consistent with the second version she had given to her family – that she had gone to bed with Lennox, co-slept with him and overlayed him accidentally thereby causing him to cease breathing.

Nevertheless, that interview post-dated her reporting to her mother, her husband, her psychologist and her psychiatrist that she had intentionally harmed Lennox. Indeed, even after the interview with police she again told her psychiatrist on 29 March 2010 she has ongoing intrusive memories of "deliberately" smothering Lennox.

From 16 June to 22 June 2010 Ms Chapman was admitted to Spencer Clinic and discharged to care of Richmond Fellowship.

Significant Matters for determination

The factual setting in paragraphs (a), (b), (c) and (d) is relevant to the issues that require determination in deciding how Lennox died. Without limiting those issues the main areas of consideration will be as follows:

  •  the nature and extent of Ms Chapman’s mental disturbance and physical illness;
  •  the extent to which she was affected by medication when Lennox died;
  •  the extent of her recollection of the day of Lennox’s death;
  •  the credibility of Ms Chapmans’ accounts to family, friends, to police and in evidence at the inquest;
  •  the veracity of information given by Ms Chapman to Mr Bradford in the 000 call; and
  • expert and objective evidence regarding events on the day of Lennox’s death.

Matters not requiring determination

At the inquest, mostly at the beginning, a number of allegations and suggestions were made that cast aspersions on the character of other witnesses. It became apparent as the inquest proceeded that these allegations were either unfounded or had no relevance in the death of Lennox. Mr Wright did not ultimately submit that they were issues that required consideration or findings. Amongst the matters raised in fall into this category are:

  1.  Who, if anybody, historically supplied Ms Chapman with drugs and medication?
  2.  Mr Chapman’s use of recreational drugs.
  3.  Whether Mrs Pisano held any pervasive negative influence over her daughter Ms Chapman.
  4.  Whether Mr Chapman held any negative influence over Ms Chapman.
  5.  Allegations of domestic violence and/or abuse having occurred during the relationship between Ms Chapman and Mr Chapman. 

Ms Chapman’s Versions of Events and Her Reliability

On 2 December 2008, Mr Chapman left home to spend a good part, but not all, of the day at work in his tattoo parlour. He left Ms Chapman alone with Lennox. Mr Chapman stated that on 2 December 2008 that he left the home and intended to work from about 10am until 3pm. Ms Chapman’s evidence was also that Mr Chapman left home to start work at about 10am.

Following Mr Chapman leaving Lennox and Ms Chapman the course of events at the family home at West Ridgley is difficult to determine. The only witness to events was Ms Chapman as no one was present in the house until her husband arrived after her call about Lennox not breathing. For the reason set out earlier in this finding relating to her inconsistent accounts and mental disturbance and illness, it is important to analyse carefully what has been reported by Ms Chapman in her various accounts.

The extent to which Ms Chapman had previously had the sole care of Lennox before that date is somewhat unclear. Ms Chapman said that she was not sure whether the day of Lennox’s death was the first time she had been left with Lennox alone. She agreed that prior to Lennox’s death Mr Chapman had gone into work "in bits and pieces".

Mr Chapman said that he had only been back at work for "a couple of days" at the time Lennox died. Indeed, he believed he had gone back to work the day before Lennox’s death, a Monday. He said that he would leave home at about 9.30am and try to be home by about 3pm. He said that he was tailoring his time at work to help his wife and to be there for his son.

The preponderance of evidence would indicate that Ms Chapman’s opportunities for having the sole care of Lennox for extended periods prior to this day were quite limited; and that she had not been alone to care for Lennox for extended periods by poor reason of her mental and physical health. 

Ms Chapman’s accounts between 2 December and 6 December 2008 ("cot death account")

On 2 December, during the 000 call, Ms Chapman told Mr Bradford that she had found Lennox in his cot not breathing and blue. She maintained such account to hospital personnel, Mr Chapman and the wider family for four days until 6 December. On that date she told Mr Chapman and her family that her account of finding Lennox deceased in his cot was not true, and that she had accidentally rolled on Lennox whilst she was asleep with him in her bed. The change of accounts was accompanied by repetitive and dramatic phrases to the effect she had "killed" Lennox and would go to jail. Her behaviour indicated a state of high anxiety and distress.

I have previously discussed the circumstances of the change in her accounts. There is no evidence that after 6 December she maintained, or at least maintained with any frequency, the cot death account.

Statutory Declaration of 8 December 2008 ("overlay account")

In her short Statutory Declaration to police on 8 December 2008 Ms Chapman stated that she had gone to bed at lunchtime taking Lennox with her and that she was tired because of taking Seroquel (Quetiapine) prescribed by her doctor. She stated:

"… I had him next to me. Sometime later I woke up and I was snug up against Lennox, he was on my left side. Lennox was laying face down. His head was facing me with his face half covered with a pillow. I can’t remember if his mouth was covered or not or if his nose was covered. I noticed he was blue. I picked him up and shook him, he coughed and blood came out his mouth and nose. It dribbled out of his mouth and a little bit out of his nose. I picked him up and bought him out to the phone. I rang Geoff immediately and then rang the ambulance and he coughed again and a little bit more blood came out of his mouth. I tried to blow into his mouth but he wasn’t breathing. At the same time I had the ambulance on the phone guiding me through what to do. About ten minutes later Geoff arrived he grabbed Lennox and put him on the change table and tried CPR. They were trying to get him to breathe; he still had a heartbeat and a pulse". 

Video Record of Interview: 23 September 2009 ("overlay account")

The reliability of Ms Chapman’s account in her lengthy video record of interview with police on 23 September 2009 interview is questionable. It is apparent that Ms Chapman had taken a significant amount of medication prior to that interview taking place where she said she had taken "Envega (sic), Logactil (sic), a couple of others". She stated that it made her drowsy.

Her presentation during that video recorded interview is consistent with someone who is extremely drowsy. Her affect is dull and flat. There are a number of inaccuracies in her Record of Interview which might well be explained by poor memory, the affect of drugs, fabrication, or a combination of those factors. Despite her demeanour, it is to be noted that her answers to questions were generally given without hesitation or pause. It gave her responses an "automatic" appearance that might usually come from either certainty of recollection or prior rehearsal. I note though that such manner of responding was exhibited whether such answers were correct or not. Her answers in evidence at the inquest had similar characteristics. The certainty with which she initially stated facts that she subsequently recanted or modified, illustrates the difficulty in accepting her evidence given in an outwardly decisive manner.

In that interview Ms Chapman said that Mr Chapman had been back at work about a week. She said in the week prior to Lennox’s death she had been helped on the days that Mr Chapman was at work by Mr Chapman’s parents. She said that they were at her house "basically every day". She said that the day of Lennox’s death was the first day she was to be alone looking after Lennox.

In that interview she said that she took more than a normal amount of medication and that she took 8 – 10 Seroquel tablets that morning. She said that this made her feel "very drowsy". She said that she fed Lennox at about 9am when the husband left, by bottle feeding. She said that she put him in his swing for a while (being a motorised swing which hung in a doorway).

She then went on to say that she put Lennox in the bath and accidentally dropped him in the bath because she was "so medicated". She said "I went to pick him up and got dizzy and dropped him". She said that as she got up she felt dizzy and fell back. She said that he went under the water and she completely dropped him in the water. She told police that she believed that she had actually blacked out for a short while and that she recalled coming to and picking Lennox out of the bath. She said that his face was under the water, but he was "okay". She said that she took Lennox to bed with her. The following exchange occurred:

"Police: Okay, what did you decide to do then?
Mother: Take him to bed with me.
Police: Okay. Why was that?
Mother: Cause I was so medicated."

She said that she put Lennox to bed in a singlet, nappy and a light blue jumpsuit. She said that this had occurred at about lunch time and she said that they were lying together and Lennox was on her left side. She believed that she went to sleep before Lennox did. She said that Lennox was on his tummy and that that was how he normally slept. She said that he was facing her and his face was sort of on the side looking at her. She was likewise on her side. She said that she placed her arm over the top of him and she pulled the covers up. She said Lennox was on a pillow, "a large Eurotype pillow". She agreed that it was one of those "big square ones". She repeated that Lennox was lying on his stomach facing her.

I note that the clear evidence from Mr Chapman was that Lennox normally slept in his own cot and on his back as recommended. I accept his evidence and the assertion by Ms Chapman is therefore not correct. Indeed the account of the sleeping position she gave to the police was most unusual. To place a very small infant on his stomach in an adult bed and then cover him with adult bedding and body defies logic and flies in the face of all safe sleeping recommendations. In particular I infer that Ms Chapman did know that the correct sleeping position for an in fact was on its back as she referred to Lennox needing ‘tummy time".

She told police that when she woke up she was half draped over him. She said, "I had rolled on him". She said that his face was covered by her and she noticed he was blue. She said that she picked him up and shook him. She said that blood came out of his mouth but only a little bit.

She said she rang Geoff and then rang the ambulance. She said Lennox was wearing the jumpsuit when she called the ambulance but that she removed it because they told her to do so. In the recording of the 000 call no such direction was given.

Importantly, in her interview Ms Chapman was asked whether Lennox made any noise after he woke up. The following answers were given:

"Police: At any stage after you waking up did he make any noise?
Mother: No.
Police: He never cried or …?
Mother: No, no he wasn’t breathing."

She was further asked whether she had a television or radio or anything on in the house before she went to bed. She said she had a television on in the lounge room.

Ms Chapman agreed that the jumpsuit (photos of which are in evidence) had been taken by police "the forensic took it".

Ms Chapman, when interviewed, told police she did not consider it was necessary to ring anybody after she had fainted in the bathroom because she was "okay when I got up". She was not concerned it might happen again. The following passage is relevant:

"Police: Did you think about the possibility that you weren’t in a state to look after him?
Mother: Yeah.
Police: Did you think that you weren’t in a state to look after him that day.
Mother: Yeah, I wasn’t that day."

Further, Ms Chapman was asked about sleeping with Lennox:

"Police: Had he ever slept with you in bed before?
Mother: Yes.
Police: How many times had that happened?
Mother: A few times.
Police: And that was while Geoff was there or…?
Mother: Yes.
Police: Okay, and was there ever concerns raised about him sleeping with you?
Mother: No."

There were quite clearly concerns about Ms Chapman sleeping with Lennox expressed by Mr Chapman and Mrs Pisano.

Ms Chapman told police that she had never taken as many Seroquel tablets once before as she did that morning. The following exchange occurred:

"Police: Had you ever taken that many Seroquel tablets at once before?
Mother: No.
Police: How many is the most you had taken at one go?
Mother: That’s the most I took.
Police: Sorry, before that? On this day you took 8 – 10. Normally you take one. Were there other days when you took more than one?
Mother: Yeah.
Police: How many did you take that time?
Mother: Only a couple.
Police: What effect did that have?
Mother: The same.
Police: As in?
Mother: Makes you drowsy.
Police: Okay and when you took a couple of tablets did you have any fainting episodes or anything?
Mother: No.
Police: On that occasion how many times did you take more than you should have?
Mother: Only a couple.
Police: Did you tell your doctor at all that you had over medicated previously or…?
Mother: Yes.
Police: And what was his reaction to that?
Mother: I shouldn’t do it.
Police: Did he say why?
Mother: Cause it makes you drowsy and… and dizzy.
Police: Was this conversation before or after Lennox’s death?
Mother: Before."

It is to be noted that there are no such reports of overmedicating to Dr Kirkman in his evidence and it is abundantly clear that the Seroquel had only been prescribed for Ms Chapman the afternoon before Lennox’s death. Therefore, the opportunity to have taken more than the prescribed amount had not existed until the night before Lennox’s death.

Sworn evidence at Inquest

Her evidence at inquest was generally similar to the account in her interview with police, that being: (a) she took an overdose of Seroquel; (b) dropped Lennox in the bath; (c) took him to bed with her; and (d) woke to find him not breathing.

When asked about her recollection of the day Lennox died Ms Chapman said in answer to the question whether she had a clear memory of that day that "I see different bits of the day".

She said that she had a "really rotten night". She said that she wasn’t sleeping at all the night before and that Geoff was looking after Lennox because she couldn’t do it.

She said that she and Mr Chapman got up. She said that she fed Lennox on the couch before Mr Chapman went to work. Ms Chapman volunteered that Mr Chapman had been to work before but that usually friends would come up or Nan or Pop or her mum or step-father or her father .

In any event, she was not expecting anybody to come and help her that day.

Prior to that people had come to help. She admitted she was anxious being left alone with Lennox that day because she wasn’t sure she could cope.

She said that when Mr Chapman left she took 8 – 10 Seroquel tablets. She believed she took "a leaflet of the tablets or a foil of them". She said that there is "10 in a slab".

Again in evidence she said that she had been taking that medication for a couple of weeks. When challenged that she had not had that medication prior to the night before Lennox’s death she conceded that "I couldn’t remember because I was on so many different meds". Even after prompting she could not remember whether it was a new medication or not.

She said that the Quetiapine made her "very drowsy, very dizzy, disorientated". She conceded that Dr Kirkman had warned her not to take too many of those and that she went ahead and took that number anyway.

She later said when pressed that she could not really remember Dr Kirkman saying that but there was a warning on the box. She then conceded, however, that that was something she knew because she had seen on boxes hundreds of times since. She said she felt dizzy when she was bathing Lennox. She said that she felt the effects of the Seroquel about an hour or two after taking it.

She said that she put Lennox in his swing for a period and then he began to cry. She said he was in the swing for about half an hour "I reckon". However, she conceded that she did not really know how long it was. She said that he was in front of the television looking at the colours while she was adjacent to Lennox doing some things in the kitchen. She did not go and have a shower or bathe. She said that she recalled her mother ringing about an hour after Mr Chapman left and then her brother rang her. She believed those callers could tell how she was. When asked if she said anything about feeling drowsy she said she did. She told them "I said I was very tired".

She said that when Lennox cried that made her distressed. She did not believe Lennox was crying because he was tired because he had not been up that long.

She believed that she put Lennox into the bath at about 11.30am after he had been crying in his swing. When questioned as to what had happened in the approximately 2.5 hours since the husband had left she said "I honestly couldn’t tell you. That day is so distorted to me". Ms Chapman was asked "Would it be fair to say then that, when you reflect on it, calmly, here today, that you really can’t say how you filled up the morning with any certainty?" She answered "Not really, no".

She conceded that Geoff left at around 9am and that she took Lennox for a bath not long before lunch which would have been about midday. The only activity she could recall for the entirety of the morning was feeding Lennox and putting him in his swing. Ms Chapman gave a clear recollection of bathing Lennox in a baby bath which was placed inside a spa bath. She said she placed him in the bath because she wanted to settle Lennox down.

She said that he was in the bath for 5 – 10 minutes and Lennox loved the bath. She repeated that she had dropped Lennox about 10 – 12 inches back down into the bath when she felt faint and that his head went under the water of a half filled baby bath. She said she had a clear recollection of that occurring.

She said Lennox was "okay" after being dropped in the bath, although she conceded that he was fully under the water. She said; "When I came to, he was lying on his back in the bath with his eyes open……. It’s one of the flashbacks that I have from that day."

She said Lennox was completely normal after the incident and that he was moving. He did not cough after being fully submerged in the water. She said that he did not even splutter. She said that she made sure Lennox was okay after that incident and then decided to have a sleep. She said that she was extremely drowsy "I couldn’t keep my eyes open".

She changed him after his bath and placed him in a singlet, nappy and jumpsuit. She agreed that the photographs taken by police showing a jumpsuit on the ground in Lennox’s bedroom on the day of his death was the jumpsuit she had placed him in. She said that she wrapped Lennox up and put him in the bed next to her on her left side. She repeated that she placed him on his belly. She said she did that "because I used to alternate him. I used to put him on his back and then I would put him on his belly, put him on his back". The question was put to her "So some sleeps he would be on his tummy, some sleeps would be on his back?" She answered "Yes because the nurse said they should have some tummy time."

She was asked "Did Geoff do the same thing when he put him down or don’t you know?" She answered: "I’m not sure. Geoff I think would usually put him on his back".

The following exchange also occurred in the course of Ms Chapman’s evidence:

"Question: When you had Lennox, perhaps at the hospital or perhaps with the health nurse when she came to visit, did they talk to you about SIDS or safe baby sleeping habits, do you remember that being an issue?
Answer: No.
Question: Do you dispute that they raised that with you?
Answer: I can’t remember.
Question: Why would you place him face down in bed?
Answer: I didn’t place him face down, his head was on the side facing me.
Question: But on his tummy?
Answer: Yes.
Question: Were you aware in any way that that wasn’t a safe thing to do?
Answer: At that time no.
Question: You weren’t aware that is was a no-no, an absolute no-no to place a child on his stomach in bed at that age.
Answer: No".

She went on to say in evidence that she was lying on her side facing Lennox and that she was cuddling him. She said she went to sleep pretty quickly. She could not remember whether Lennox was asleep as she went to sleep or not.

Ms Chapman was also asked what had occurred when she woke up. She said:

"When I woke up, I was half way on top of him almost covering his face but I could see straight away that he was turning blue. I picked him up, panicked, shook him cause he wasn’t breathing. I was screaming out his name… There was blood in his mouth, and I shook him. By this time I was absolutely hysterical. And I got out of bed and went to the hallway and I sat him on the floor next to the phone. I was holding him calling Geoff. And told him that he, he was turning blue. He wasn’t breathing. Geoff dropped the phone and said just ring the ambulance, ring the ambulance. And so as soon as I got off the phone to Geoff I rang the ambulance, just rang the ambulance".

"Question: Okay, you rang the ambulance, do you remember what happened next?

Answer: No. They were trying to guide me with the CPR but I couldn’t take it in, I was too hysterical and was trying the best I could, but I wasn’t doing a good job.

Question: Do you remember what you did for the CPR, did you do some of the breathing and things, or did you not get any of it done?

Answer: I did some of it, I remember, it’s so hard to remember, the ambulance put him lying on his side, and see if you can clear his airway. And then I put him back on his back and tried to listen to what they were telling me.

Question: Did you breathe into his mouth, do you remember doing that?

Answer: Yes.

Question: Do you remember pumping his chest or pushing his chest?

Answer: Yes.

Question: Do you really have a sort of clear recollection of how that all went or is it all just

Answer: No I don’t.

Question: A horrible blur?

Answer: It was just awful".

When giving evidence the tape of the 000 call was in its enhanced form was played to Ms Chapman. She did not accept that the cry apparent on the tape was that of Lennox. The following exchange occurred:

"Question: And that’s you on the phone the day Lennox died?
Answer: Yes.
Question: Now, do you hear that baby cry just before we stopped the recording?
Question: Yeah, heard a little sound, yes.
Answer: Okay, what was that little sound?
Question: I don’t know. It must have been Lennox. I don’t know but I was pressing on his chest.
Question: You accept that that’s Lennox’s cry?
Answer: I don’t know. All I know is he wasn’t breathing. I know he wasn’t breathing when I woke up.
Question: Well, I’m sorry to press you but this is important. Do you accept that that was Lennox’s cry and that was the noise that we heard then?
Answer: I don’t know.
Question: Do you have any explanation as to what other noise it might be?
Answer: No, I don’t have an explanation.
Question: Was there anything else in the house or near the phone that could have made a noise like that that day?
Answer: I don’t know. I had the television on, we had a kitten, we had a cat, we had a cockatoo".

It was plain that Ms Chapman had discussed the issue of Lennox making a noise with her general practitioner Dr Reynolds since Lennox’s death and before she gave evidence. She gave evidence that as a result of those discussions she believed that Lennox may have made a noise because of the pressure she was placing on Lennox’s tummy or chest. However, she conceded in evidence that she could not remember actually doing those things. Rather she said she was holding him in one arm whilst holding the phone in the other. In any event, as will be further discussed the expert witnesses and Mr Bradford are in no doubt that it was a normal baby vocalisation. This is also plain upon listening to the recording. Ms Chapman’s denial in evidence was most surprising.

In evidence when the phone call was played to Ms Chapman when Lennox’s clear second and third (and enhanced) noises were played to her she did not agree that it sounded like a baby.

The following exchange occurred:

"Question: So when he said (the communications officer) said is that Lennox making noises did you hear yourself saying no to that question?
Answer: Yes.
Question: So you were telling the truth when you said that?
Answer: Well, yes.
Question: What would you say if this Court were to form the view that that was a baby noise?
Answer: I don’t know."

When giving evidence at the inquest Ms Chapman was distressed at times as was most understandable. No doubt the task of giving evidence was most difficult for her. However she was well presented and had the demeanour of a witness who was lucid and attempting to answer questions in a calm and responsive way. There was no discernible appearance that she was affected by any substance or medication. The answer that suggested that the cat or cockatoo may have been responsible for the cry appeared to be an attempt to maintain her account that Lennox was deceased at that time.

Ms Chapman said she had no recollection of Lennox shaking that day. Of course she had previously agreed that Lennox was shaking when that specific question was asked of her by the operator. She did not, however, volunteer that as one of this symptoms in the 000 call. She did not report shaking to Mr Chapman when she called him.

She was asked so why did you say he was shaking if he was not shaking:

"Answer: I don’t know.
Question: You’re distressed aren’t you in this call but why would you say he was shaking when he wasn’t?
Answer: I don’t know.
Question: Can you think of any reason why you would say he was shaking?
Answer: No.
Question: Were you trying to mislead the officer?
Answer: No.
Question: And you must have been trying to do your best to try and get help for your baby so why did you tell him something that wasn’t right?
Answer: I don’t know.
Question: Why did you say he was shaking?
Answer: I was out of my mind, I don’t know".

Ms Chapman’s evidence before the Inquest is not consistent with her having a clear recollection of events.

When questioned at the inquest about why she had subsequently admitted to having intentionally harmed her child Ms Chapman said "I wanted an explanation I wanted something, I wanted to be responsible for this". By that I infer she said she meant that she did not intentionally harm Lennox, but knew that Lennox’s death was her fault because she had overlain him. As Mr Wright submitted merely demonstrate the extent to which Ms Chapman was "wracked with guilt" over her baby’s death.

The following relevant exchange occurred in her evidence:

"Question: You have said in answer to that question I think you said it before that when you told the doctors, when you told Dr Kirkman that sort of thing and when you told Geoff that sort of thing that you wanted an explanation. Remember you’ve said that just now and you have said it before haven’t you.

Answer: Yes.

Question: To me when someone says I want an explanation it means that they don’t know what happened. And they’re looking for an answer. They’re looking for the facts because they don’t know what they are. Is that why you were looking for an explanation, because you didn’t know what happened?

Answer: I thought I knew what happened but then I would question myself, because I was so psychotic.

Question: You would question yourself because you were psychotic at the time of Lennox’s death?

Answer: Yes".

The expert evidence by no means allows me to find that Ms Chapman was "psychotic" at the time of Lennox’s death. I cannot find that any person treating her would have conveyed this diagnosis to her. Her evidence was another example of her conveying as a fact something which was not, and also seeking to increase the degree of her mental disturbance.

Further, in reference to her interview with the police Ms Chapman said:

"What I told the CIB is the best I can do….. I am trying really hard because now I see that day in flashes, bits and pieces …"

The following was then put to her in evidence:

"Question: So is what you are saying to us is that you really, as to what happened that day and to what you did that day, you just don’t have a clear memory, a clear story in your head, is that where you are at?
Answer: Yes".

Further, at the following exchange occurred as to her memory:

"Question: What are the doubts that you have please?
Answer: Umm, it is really hard to explain because when my brain was like that way it was you can’t, you can’t you start to question yourself what is real and what’s not because people are telling me things that aren’t real that I think’s real.
Question: So it’s a fair summary, I don’t want to interrupt you – is it a fair summary that you have reached the point after all this time that you don’t really know what’s real and what’s not real in your mind about what happened that day?
Answer: Yes". 

Ms Chapman’s accounts of deliberately harming Lennox

I now summarise Ms Chapman’s oral accounts to several others of deliberately harming Lennox. It is very important to determine whether any such admissions have veracity. I have already explained previously the context in which most of those various accounts were given.

To her mother, Mrs Pisano, Ms Chapman first spoke of a deliberate smothering when being admitted to the Spencer Clinic on about 9 December 2008. Interestingly, she also then disclosed to treating professionals that she had a long history of hearing voices. She explained such disclosure by stating that by then she knew she needed help. I accept her evidence on this point.

To her husband, Mr Chapman, she first spoke of deliberately harming Lennox on 30 June 2009.

To Dr Kirkman, Ms Chapman had only given the overlay account until August 2009 when she disclosed to him intrusive memories of smothering Lennox with a pillow. From then on she told Dr Kirkman of ongoing memories of smothering Lennox with her hand. She was unable to explain why she changed her account to Dr Kirkman. Dr Kirkman had previously received a consistent, repetitive account of accidental overlay and was basing his treatment upon that.

He then became unsure as to what was the correct account. When the terms of the "confession" made Ms Chapman to Mr Chapman was put to him he said:

"I think that considering the graphic nature of her description, that that seemed to me to be more consistent with what -, with the truth. The first deliberately smothering him. I can’t be - I can’t make any guarantees about that. It doesn’t seem to me, if you look at the alternative, would she come up with that story, that she had deliberately suffocated Lennox? Does that make sense somehow? I don’t think it does to me. I don’t think somebody would, out of a sense of guilt -"

Dr Kirkman further said:

"If that really happened, then I think anyone would have daily intrusive recollections of that happening, of you doing that to your baby. She said she was plagued by these flashbacks and she had said that for many months without – of his death without saying what they were and I think when she said this was what she was remembering, it to me makes sense; it’s consistent with what I read in the newspaper even though that’s obviously outside of my own personal garnering of information and I think it is consistent with this sort of chronically wanting to tell over and over and over again, what really happened on that day, What if I did something? What would happen to me? Would I go to prison? And I think at that point I felt I could no longer really provide treatment for Katrina. And I felt that really what she was suffering was probably not a treatable condition, in other words that if you deliberately suffocated your child I can’t think of any mechanism whereby you could psychologically aid someone not thinking about that all the time, it is just a fact."

Psychologist Bernadette Smith also had a long standing professional relationship with Ms Chapman. To Ms Smith, Ms Chapman maintained only the deliberate smothering account. It was first given to Ms Smith on 13 December 2008 whilst Ms Chapman was in Spencer Clinic.

Ms Smith gave articulate and intelligent evidence about Ms Chapman’s mental health and the reliability of Ms Chapman’s accounts. I set out relevant passages of Ms Smith’s evidence:

"On the 13th of December, she said that she had images of her hand over Lennox’s face, and of him turning blue. And she remained distressed with those images. That she’d be locked up. She believed that she needed to be punished and she sees herself as bad."

"She had already held a view that she was somehow bad and had somehow harmed the child. And it seemed congruent that upon his death, that she must have somehow been to blame for that, was my interpretation at the time. I’m not sure if that actually answers your question. But what concerned me was that her story changed. She told me that - putting her hand over his face, and then outside once she was being seen by me in the private practice, she told me two other stories - one that he was on the change table, and she smothered him, and another one that she had dropped him in the bath. When confronted with Katrina I’m confused, she wasn’t able to clarify, but she simply became increasingly distressed. So the - her capacity to cognitively process things at this point in time, was pretty limited, and that perhaps was my concern was while I can’t say confidently whether or not she was telling the truth or not. I think sub-consciously she believed that somehow she was to blame. So whether or not these thoughts that she has formed, simply just re-affirmed to her that, you know, I must be to blame. "

"Question; with your experience and training, if those recollections are changing to that extent, what do you say as to the reliability of any or all of them?...

Answer; It would question the reliability. I -, what I do know about Katrina is, I am fairly confident that her capacity to function was incredibly limited. And my work therapeutically with her after Lennox’s death, her capacity to work in a cognitive manner, for psychologists working with your clients in a cognitive way, that capacity to be able to stop, to reflect, to reorganise your thinking, she just simply did not have the capacity to do that. So we had to work in a very strictly behavioural goal oriented approach, working on her, her life skills. And whilst I didn’t see her prior to Lennox’s death, I’m fair -, you know confident that her capacity to function was fairly limited. And her capacity to reason was probably quite impaired, because certainly the thing that she, that I certainly wasn’t able to get from her, was any capacity to reflect, any capacity to ground her perceptions, her recollections, they were simply ruminative, and she was simply not able to expand on them, but simply was ruminating on them. So any capacity is sort of you know, verify or to go through those, was very limited in a cognitive way, ..."

Ms Smith continued to see Ms Chapman consistently after she was discharged from Rivendell Clinic in April 2009. After discharge Ms Chapman still maintained the deliberate smothering account in sessions with Ms Smith. This was despite her giving the accidental overlay account to Dr Kirkman and in her formal police interview in the same period.

Ms Smith characterised Ms Chapman as having borderline personality disorder, marked by substance use, a fragile sense of self, and seeing herself as "bad". Ms Smith noted that Ms Chapman’s inability to handle stress and inability to reason were also features of this disorder. Ms Smith also noted that transient psychotic episodes can also be a feature of a borderline personality in acute stress. I accept Ms Smith’s opinion.

Ms Smith last saw Ms Chapman on 3 February 2010, by which time Ms Chapman was in the care of the Richmond Fellowship.

As discussed, Ms Chapman could not provide clear reasons for giving inconsistent accounts to different persons at a similar time. She simply emphasised that she "wanted to feel responsible". 

Summary of Ms Chapman’s Reliability

Ms Chapman’s reliability in recounting events, whether in evidence, to police or others, is significantly called into question because of the following matters:

(i) Her initial version of events as outlined to both Mr Chapman and the Tasmanian Ambulance Service Officers was that she woke, went to Lennox’s room to find him in his cot, cold, blue and not breathing. On her own evidence this is untrue. Despite her overt distress during those calls she was able to actively mislead the communications officer and her husband as to what had occurred before that call. She did so twice, once to her husband and once to the 000 operator. Ms Chapman resiled from that version in the days afterwards (citing guilt over having caused the death of Lennox by overlay as being the reason that she had lied). Nevertheless, despite the urgency and importance of the call Ms Chapman was admittedly calculatedly dishonest when she spoke to her husband and the Tasmanian Ambulance Service in the 000 call about the events prior to the call.

(ii) There are serious doubts about the overlay account. The description of the position in which she says she placed Lennox is bizarre. Ms Chapman would have been well aware that to place a very small infant in a prone position upon a large pillow with a doona and adult body covering him would pose a high risk of suffocation. It is very difficult indeed to accept that she did this. Although she had taken him to bed on other occasions, she "feared" him, saw his face as distorted, and found it difficult to be near him. There is ample evidence from her and others that she did not even see Lennox as a "baby". A co-sleeping situation may not sit with such inability to bond.

(iii) Ms Chapman has variously provided other versions of Lennox’s death to both Lennox’s father, her mother, Bernadette Smith and Dr Kirkman whereby she advised them that she had intentionally smothered and/or choked Lennox by placing her hand or a pillow or cushion over Lennox’s face. Therefore, she has variously supplied no less than three different versions of events.

(iv) In her evidence before the inquest she conceded that her memory of the day was very poor and that she only has "flashes". The content of the "flashes" or "intrusive memories" were withheld from Dr Kirkman for many months. As discussed Ms Chapman had a history of withholding information relevant to her treating professionals when she thought that such disclosure was not to her advantage. The voices in the head and distorted visions of her baby are examples. There is some real force in the proposition that when she finally disclosed those to Dr Kirkman they were flashes that she was genuinely experiencing, as opposed to reporting a reconstructed account. The evidence indicates that such flashes were involuntarily presenting themselves repetitively to Ms Chapman’s conscious mind. As such Dr Kirkman held the view that the content of those could well represent the correct memory. His evidence was powerful and coherent. In the therapeutic setting she would probably have felt able to finally disclose those intrusive memories. On the contrary the mechanical overlay account given to police and in evidence seemed to represent the "official" account that apportioned blame partly to herself but also exculpated herself by the lack of intention to harm her baby. Ms Chapman’s dramatic statements about going to jail due to accidentally overlaying her baby were irrational in the extreme. However, they are less irrational if Lennox’s death was not caused by a sleep accident but by a deliberate act. The references to "confession" and "killing" make more sense in that context, and yet Ms Chapman is still able to satisfy her guilt by an account involving partial blame. At the time of making those statements she was not aware that the 000 call had been recorded, and that would show that Lennox did not die as a result of an accidental overlay.

(v) The evidence from Ms Chapman and indeed her own drug taking history would support a finding that Ms Chapman may well have taken an excessive amount of Quetiapine on the day in question.

Professor Mullen’s evidence given to the inquest is particularly enlightening as to the effect of taking Quetiapine on the "laying down" of reliable memories. He noted that Quetiapine causes a drop in blood pressure even if it does not actually result in feeling faint or fainting or feeling light headed. He said that a drop in blood pressure affects the functioning of the brain and that the first of the higher functions of the brain to suffer as a result is the ability to lay down reliable memories. If Ms Chapman took a large amount of Quetiapine that morning such that one would expect her blood pressure to have dropped quite significantly. The episode she describes in the bathroom is consistent with that.

However, I have some doubts about whether she did in fact take excessive Quetiapine or whether that account was manufactured or greatly exaggerated explain her dropping Lennox in the bath. Although she suffered an addiction to Mersyndol, the evidence is that, since the birth of Lennox, she took the correct doses of medication prescribed to her. She knew from Dr Kirkman’s advice the previous day that dizziness was a side effect. She was also savvy in the use of the internet in searching medical matters. It is very strange that she suffered such an episode at the very time that she was holding Lennox near the bath. Further, it might be thought unusual that a mother would drop her infant into the water and not instinctively prevent his fall upon the onset of the dizziness. Further, to give clear evidence that she saw him lying under the water with his eyes open suggests that she had a reasonable chance to observe him, and may not have been acting in a hurry. I note too that the disclosure of the bath incident several days after Lennox died was in the context being very concerned that the incident would be found by the pathologist to have caused death, and she would go to jail. It appears that the disclosure could well have been motivated by the fact that water in Lennox’s body might be found at autopsy, and how it could possibly be explained in an "accidental way". Similarly, before Dr Ritchey’s report of the post-mortem was prepared on 23 February 2009, she told two witnesses, Jane Webberley and Stephen Radford, that she feared the bath oil in Lennox’s bath on that day may have caused his death. She did not tell them about dropping Lennox in the bath. However, she did tell her friend Megan Billing at around the same time that she "thought" she dropped Lennox in the bath. Whilst she was giving varying accounts of the bath incident to different people she was clearly dwelling upon it. I do accept Ms Chapman’s account that Lennox was in the bath but cannot determine what happened in the bath. She told the ambulance communications officer Mr Bradford that Lennox did not have a fall. Either that was an untruth or he was not dropped accidentally in the bath.

(vii) The evidence from Dr Kirkman and Professor Mullen is to the effect that Ms Chapman was in a poor state of mental health at the time of Lennox’s death and that she may well have been suffering from a significant depressive disorder of some type on that day. According to Professor Mullen this affects the reliability of memory laid down during such a period.

(viii) Professor Mullen’s evidence was that Ms Chapman’s poor state of physical health would most likely render her memory unreliable. He further noted that general fatigue would affect her ability to lay down reliable memories. He gave detailed medical reasons for this proposition that I accept.

(ix) It was Professor Mullen’s view that Ms Chapman had motives to inculpate and exculpate herself in relation to Lennox’s death. Further, his evidence was that her wishes to either be inculcated or exculpated would vary from time to time. He most insightfully gave evidence that as time goes on after an event, such as the death of a child, a person’s "memory" develops into, essentially, a version of events which allows people to cope best in their life. Professor Mullen’s evidence in this regard makes good sense. However, Professor Mullen forms other conclusions that I hesitate to accept in full. The first of those is that no reliance can be placed upon any of Ms Chapman’s statements about how Lennox died due to her disordered mind. Whilst I give weight to his opinion relating to the factors that would cause a lack of memory, it is very much the task of the court to analyse and determine the veracity of her admissions, and which accounts are the more plausible.

(x) There is an inherent unlikelihood that in the space of a few hours an infant would suffer an accidental near drowning incident in the bath, and then survive an accidental overlay whilst sleeping with its mother; only to die of a further accidental cause whilst its mother was telephoning the ambulance.

(xi) Ms Chapman’s evidence before this inquest was at times unimpressive. She gave the appearance of a witness whose evidence was largely reconstruction rather than a true memory. I have already referred to my reasons for this conclusion. 

The 000 Call

The recordings of the 000 call is the only reliable material available to the court concerning the events at the home between the time Mr Chapman left and the arrival of Mr Chapman back at the home shortly before ambulance officers on the day Lennox died.

The evidence of Ms Chapman’s 000 call to the ambulance service was before the court in the forms of: (a) an electronic copy of the original recording; (b) an electronic copy of an enhanced version produced by police technical officer Mr Allen Smith: (c) a transcript of the recording; (d) a statement made by Mr Bradford that included the time of various points of the call; and (e) Mr Bradford’s evidence.

The ambulance communications officer Nicholas Bradford gave careful, detailed and considered evidence as to the call and his beliefs as to what was occurring whilst it was happening. He was taken slowly through the whole recording by Mr Brown. His recall was excellent. He was not judgmental nor did he overstate any fact. He had the benefit of a clear telephone line, in comparison with the poorer recorded version in evidence. He had 16 years of experience in his work. With the benefit of that experience he had developed the skill of listening to assess the nature of the actions being taken by the person calling. In all aspects of his evidence he was a singularly impressive witness. I have no hesitation in accepting his testimony in its totality.

Mr Bradford stated he heard no noises consistent with a radio or television in the background during the call. He stated that he heard Lennox cry a number of times. It was his view that Ms Chapman’s attempts at CPR were poor and that there were several significant patches during the telephone call when what he heard was inconsistent with CPR having been administered. His judgement in this regard is evidenced by the passage of the recording when he discusses events immediately afterwards with another officer. The good evidence of Gaylene Walker, attending ambulance officer corroborates Mr Bradford’s evidence. She formed the view upon observing the lack of swelling or any redness on Lennox’s chest, that CPR by chest palpation had not been performed upon Lennox.

In that telephone call Ms Chapman is able to provide Mr Bradford with her address and Lennox’s age. She is, with one exception, immediately to responsive to Mr Bradford’s questions albeit sounding highly distressed.

She told Mr Bradford that Lennox had gone "real blue" and was not breathing. She said she was holding Lennox in her arms and that he had blood coming out of his mouth. She said he was shaking. She repeated that he was cold and that he had blood coming out his mouth. She again repeated that Lennox was cold.

Up until that point the call is broadly consistent with the report that Ms Chapman had given to Mr Chapman in her brief telephone conversation with him before she called the Ambulance Service.

However, 45 seconds into the call Lennox can unmistakeably be heard to cry out. At that point Ms Chapman acknowledges Lennox has cried. The following exchange occurred:

Operator: "Is that him crying?"
Mother: "Yeah, he just cried."
Operator: "Excellent, crying’s good. When he’s crying he’s got more than enough air. Is he on his side now?"
Mother: "Yes."

Ms Chapman nevertheless did not express relief at the fact of Lennox crying. She continued without much pause to report that Lennox was not breathing and that he was blue. She stated that Lennox had his head back as instructed. She repeated that Lennox was on his side. She told the operator that she was gently lifting his head back but that she could not see his chest going up and down.

Ms Chapman then told Mr Bradford that she went into the bedroom to check Lennox and he was not breathing. On her own evidence this is untrue. Mr Bradford asked whether Lennox was breathing. Ms Chapman said that he was not. The officer asked "Can you see his little chest going up and down?" Ms Chapman answers "no" at which point Lennox can be heard to make certainly two and possibly three further audible noises/cries. This occurs 1 minute 40 seconds into the call. Whilst those noises are not as loud or perhaps not as forceful as the first cry recorded, they are unmistakeable cries from a baby.

It is most significant that upon the second groups of noises being heard the following exchange ensued with Mr Bradford:

Operator: "Is that him making noises?"
Mother: "No".
Operator: "What’s making the noises?"
Mother: (Crying).
Operator: "Are you there?"
Mother: "Hello."
Operator: "How many children do you have?"
Mother: "Just one."
Operator: "Right well someone’s making noises in the background. Is that Lennox?"
Mother: "No. I’ve only got the television on."
Operator: "Alright, turn the telly off."
Mother: "Wait there."

At that point the phone can be heard to be put down and it appears that a sound consistent with footsteps is to be heard.

Despite the fact that it is clearly Lennox who made those noises- there can be no other possibility as to the maker of those sounds- Ms Chapman denies that Lennox made those cries. As is revealed by the recording there follows an awkward and odd passage where communication between Ms Chapman and Mr Bradford inexplicably becomes disconnected and Ms Chapman seems to have difficulty hearing the officer before pausing and then saying "hello?". I note that she had not had any difficulty doing so beforehand or at any later stage. Mr Bradford’s voice is consistently clear.

The officer asks if someone’s making noises in the background or is that Lennox. Ms Chapman replies "No. I have only got the television on". The officer tells her to turn the television off and Ms Chapman tells him to wait. Her manner in this passage is most unusual, and sounds quite artificial.

It is obvious at that point that the telephone is put down, but no noise consistent with a television or radio or similar can be heard either then, before or after.

The evidence before the court clearly shows that the flooring in the area in question was a hard tiled surface and that the television was only a short distance away from where the phone must have been placed. In addition the shape of the phone, being curved, would have allowed for sounds to be heard, even when it was placed on the floor.

Ms Chapman returns to the phone and asks Mr Bradford "Are you there?", to which he says "Okay, so is he making noises at all?". Ms Chapman replies "Just little noises". The officer answers "Little noises okay, while he is making noises he is getting some air in". Ms Chapman replies "Okay". There is no sense of relief on her part. In fact no noises from Lennox are audible at that time at all.

I find that Ms Chapman was not truthful in saying the television was on. In all of the circumstances Mr Bradford would have heard it and it would have been recorded. I am satisfied that when Lennox cried on the second and third occasions Ms Chapman appeared to inexplicably "stumble" or hesitate in a very marked way and then lie about the source of noises. 

Amongst the significant features in the 000 call are the following points:

(i) Ms Chapman reported Lennox as having stopped breathing. This is incorrect. She would have been able to easily determine that his chest was moving up and down. Any parent would carefully check such a vital sign of life.

(ii) Ms Chapman reports him as being "real blue" and having blood coming out his mouth. Whilst he may have been pale he was not on all the evidence obviously blue.

(iii) She denied to Mr Bradford that Lennox suffered any fall, although on her evidence she dropped him 12 inches into the bath.

(iv) She does not mention the bath incident at all.

(v) She was asked whether he was shaking and she says that he was shaking. She did not volunteer that but seizes on the suggestion that she would not have otherwise volunteered.

(vi) She reported that he was cold. The evidence from the attending ambulance officers was that Lennox was not cold.

(vii) Ms Chapman acknowledges the first cry but expresses no relief at it as would be expected.

(viii) He cries two times more shortly after. Ms Chapman denies the noises have been caused by Lennox. This is an untrue statement.

(ix) The cries were not distressed cries but rather a normal or communicative type cry.

(x) There is a strange "stumble" or hesitation/communication difficulty with the operator at this point – when Ms Chapman is untruthful about Lennox’s second and third cries.

(xi) Ms Chapman is untruthful about finding Lennox in his cot.

(xii) It is unlikely that Lennox was wearing a jumpsuit during the call as Ms Chapman stated.

(xiii) Ms Chapman tells an untruth about the television being on.

(xiv) At one point Ms Chapman makes a heavy blowing sound, purportedly in response to instructions from Mr Bradford to breathe into Lennox’s mouth. However the breaths had the clear hallmarks of a person blowing into the air, but wanting the operator to hear the breaths.

It is only a matter of about 11 minutes from the beginning of the call to when Mr Chapman arrived and can be heard on the recording. Mr Chapman’s evidence to the inquest was that when he arrived at the scene Lennox was not breathing. The heart wrenching nature of his reaction heard in the call is consistent with finding Lennox in that state.

I am satisfied that by the time Mr Chapman arrived and examined Lennox, Lennox was deceased.

At the time Lennox cried out audibly during the 000 call, he was alive and was likely to be in no particular distress. My reasons for this conclusion are based upon the expert evidence as set out below. Even if Lennox was distressed his breathing was not in any way significantly compromised.

Therefore, I am able to find that Lennox died in the 9 minute period between 2:15:28 pm and 2:25:00pm.

The Cause of Lennox’s Death

Forensic Pathologist, Dr Donald Ritchey, undertook an autopsy on Lennox. He stated in evidence:

"Autopsies of children in particular are done to a rather rigorous set of protocols that include, you know, documenting the case very carefully with photographs, taking lots of histologic sections for looking under the microscope, as well as blood for toxicology and other samples for testing of microbiology to assess for other possible causes of death. And we do these regardless of, of the type of case that we’re involved in."

Dr Ritchey determined that autopsy revealed a well-developed child without congenital abnormality. Toxicology was negative. Significant aspiration and pneumonia were not present. There was nothing found at autopsy that would account for death. Dr Ritchey classified the cause of death as "undetermined". He stated that his findings at autopsy would be consistent with all three accounts given by Ms Chapman - the cot death account, the overlay account, and the deliberate smothering account.

The principal sources of evidence regarding cause of death are to be found in the reports and evidence of Dr Ritchey and the reports and evidence of Professor Byard and Dr Terrence Donald.

Dr Donald is an experienced medical practitioner and paediatrician. He is the immediate past Head of the Child Protection Services at the Women’s and Children’s Hospital in Adelaide. He has qualifications in Community Paediatrics and a Diploma in Clinical Paediatric Psychiatry. He has held many positions. His current position as a consultant at that said hospital involves primarily clinical work to do with the assessment of children where there is a suspicion of child abuse. He has a major role in supervision and teaching of training registrars and fellows as well as medical students. He has given expert evidence in Coronial Inquests, Family Court proceedings, and Criminal trials around Australia and New Zealand.

Professor Byard holds medical degrees from both Tasmania and Canada, and has a qualification in family practice. He undertook the study of pathology and obtained Fellowships from the College of Physicians & Surgeons in Canada, the College of Pathologists in the United States, the Royal College of Pathologists in the UK and the Royal Australasian College of Pathologists. He also has a Master of Medical Science and an MD, the latter being the equivalent of a PhD in medicine. Both of these are higher degrees that dealt with sudden unexpected death in infants and children. On this subject he is the author of over 475 papers published in peer reviewed journals.

Professor Byard currently holds two positions: the Chair of Pathology at the University of Adelaide and Senior Forensic Pathologist at Forensic Science South Australia. He has held the latter position since 1999 on a full time basis.

At the inquest Dr Donald and Professor Byard gave their evidence together. They were in agreement on all relevant matters of opinion. Their areas of expertise overlapped to a significant degree. However, there were parts of the evidence that were appropriate for the opinion of only one of those experts. In other aspects of their evidence they were able to comment from their differing perspectives or supplement the evidence given by the other. This manner of receiving evidence was very effective. Their evidence was of high quality and unchallenged by Mr Wright or Mr Chapman.

It is plain from the expert evidence available to this inquest, which has not been challenged, that Lennox was alive when the cries are to be heard on the 000 call. Lennox was deceased by the time Mr Chapman examined Lennox and certainly by the time ambulance officers arrived only a matter or moments after he did.

Dr Donald explained in evidence the nature of the baby’s noises:

"I don’t think it’s a cry, I think it’s a vocalisation. It’s not a distress – distress noise, and to me that confuses me even more because it’s like the baby was interacting with his mother. Particularly I think that the – I identified three periods of vocalisation, there was a question about a fourth, but there’s clearly three. The first one was the longest. That was the one when I listened to it the first time I thought that baby’s talking to his mother, it was a cooing – it wasn’t the kind of noise that you expect to hear from an infant who, let’s say, has just survived an episode of asphyxia, that would be a lustful clear cry, probably with a distressed component to it. So I – I mean I don’t know what it means but it just concerned me even further because the next point is the point that Roger Byard just made, between the phone call at thirteen past four to the arrival the baby’s died, but the baby to all intents and purposes – you must consider from my point of view that the baby was breathing normally and perhaps even happy at the time the phone call was made."

It was explored with Dr Donald and Professor Byard whether the cries might be what was known as "agonal gasps" or "death rattle" of a dying infant. They were most emphatic that they were not. Dr Donald said that such sounds were completely different, resembling a sob and then a rattle. I accept this evidence.

I find upon the evidence of Dr Ritchey, Professor Byard and Dr Donald that there is no disease process or illness in this child such as would explain his death during the period in question, that is, between the last of the cries and the arrival of Mr Chapman/ambulance officers.

Natural conditions such as a cardiac conduction abnormality or myocarditis that might be considered as possibilities for the sudden stopping of the heart can be excluded as being no more than the remotest possibility to explain death. Professor Byard and Dr Donald give detailed reasons for this conclusion that I fully accept.

The possibility of Lennox having been dropped or having fallen during the period in question can be excluded. Professor Byard stated that there was no injury present sufficient to cause Lennox to be concussed let alone to suffer a brain injury such as would stop Lennox’s respiration. Dr Ritchey also reported that there was no external or internal evidence of trauma or injury.

The possibility of drowning or submersion in water during the period in question can likewise be excluded. There was no opportunity for that to have occurred during the 000 call as it was plain that Ms Chapman was essentially present by the phone through the whole period. Further, there is no evidence that Lennox was wet or damp upon the arrival of the police or ambulance officers.

The realistic scenarios open to the court as to the cause of death are that: (a) Lennox’s death occurred as a result of intentional asphyxiation by the placing of a hand or other item over Lennox’s nose and mouth; or (b) that Lennox’s airway was occluded by virtue of incorrect, but well intended, positioning of Lennox’s head during attempted CPR.

Professor Byard and Dr Donald could not exclude the possibility of "mal-administered CPR", involving unusual placements of Lennox’s head, as being the cause of Lennox’s cessation of breathing. Mr Wright submitted that it was plausible that this was the case.

The evidence of Professor Byard and Dr Donald is that Lennox may have had some mild abnormality of his larynx and airways being a condition involving soft cartilage in that area. Dr Donald said:

"- Lennox did have a degree of floppiness within his larynx and within the upper part of his trachea. Now because of that and the presence of his ears it was obviously important to consider the possibility of some cartilaginous abnormality in the laryngotracheal area. Now most children who have floppiness in those areas don’t have apparent anatomical abnormalities but they do have degrees of abnormality when their airway is what’s called screened using imaging techniques, so it’s quite possible that if Lennox had had imaging there might have been some evidence of some closure of the larynx or upper trachea at the time of the imaging. Professor Byard will comment on the histology of it, but from my point of view with that family history and that story I would want to consider it to be the case that Lennox did have a degree of floppiness, and that’s the best way to describe it, in his laryngeal area and the very upper part of his airway, which of course fits onto the bottom of your larynx."

He further said:

"… I don’t think you can exclude the possibility that there was some propensity to airway obstruction. Normally in a child who’s got this problem it becomes more obvious when the child has an upper respiratory tract infection and that’s when often they have difficulty breathing, but on the other hand if his head and trunk was placed in a position where there may have been a tendency for the upper airway to kink then maybe it could have done that. I wouldn’t want to exclude the possibility that he had a predisposition to easier than normal upper airway occlusion, but there’s nothing in what I’ve read, nothing in what we’ve looked at that can take it any further than that, you’d just have to say you can’t exclude the possibility."

Dr Donald indicated that Lennox’s airways might be blocked during CPR if his head was placed in marked forward flexion, that is, with chin to chest. Alternatively, marked side twisting of the head could have the same effect.

However, that explanation for Lennox’s death is, on the totality of the evidence before this very unlikely.

In the 7 weeks of this child’s life there had been no recording of any respiratory difficulties by Lennox at any time prior to the day of his death, with the exception that Mr Chapman reported noisy breathing. He said his now adult daughter had the same type of breathing when she was a baby.

Ms Chapman gave no evidence of Lennox’s head being in any strange or fixed position such as might occlude his airway to any person on the day or at any time thereafter to police or in her evidence. Whilst I am not able to accept what she said, it was apparent on her own evidence, and that of Mr Bradford, that she did little effectively in that regard.

I am satisfied that when Mr Chapman arrived home Lennox was on his back with Ms Chapman over him appearing to attempt CPR.

It is a most unlikely hypothesis that Lennox’s cessation of breathing was caused by Ms Chapman unwittingly, and contrary to Mr Bradford’s clear instructions, positioning her child’s head forward onto his chest or twisted to one side whilst performing CPR.

I am mindful that I am considering factual findings relating to most serious conduct. Whilst coronial cases require findings on the balance of probabilities, special considerations must apply in these circumstances.

In this regard all judges of the High Court in Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd [1992] HCA 66 said:

"The ordinary standard of proof required of a party who bears the onus in civil litigation in this country is proof on the balance of probabilities. That remains so even where the matter to be proved involves criminal conduct or fraud ((1) See, e.g., Hocking v. Bell [1945] HCA 16; (1945) 71 CLR 430, at p 500; Rejfek v. McElroy [1965] HCA 46; (1965) 112 CLR 517, at pp 519-521). On the other hand, the strength of the evidence necessary to establish a fact or facts on the balance of probabilities may vary according to the nature of what it is sought to prove. Thus, authoritative statements have often been made to the effect that clear ((2) Briginshaw v. Briginshaw [1938] HCA 34; (1938) 60 CLR 336, at p 362; Helton v. Allen [1940] HCA 20; (1940) 63 CLR 691, at p 701; Hocking v. Bell (1944) 44 SR (N.S.W.) 468, at p 477 (affirmed in Hocking v. Bell (1945) 71 CLR, at pp 464, 500); Rejfek v. McElroy (1965) 112 CLR, at p 521; Wentworth v. Rogers (No.5) (1986) 6 NSWLR 534, at p 539 or cogent ((3) Rejfek v. McElroy (1965) 112 CLR, at p 521) or strict ((4) Jonesco v. Beard (1930) AC 298, at p 300; Briginshaw v. Briginshaw (1938) 60 CLR, at p 362; Helton v. Allen (1940) 63 CLR, at p 711; Hocking v. Bell (1944) 44 SR (N.S.W.), at p 478 (affirmed in Hocking v. Bell (1945) 71 CLR, at pp 464, 500); Wentworth v. Rogers (No.5) (1986) 6 NSWLR, at p 538) proof is necessary "where so serious a matter as fraud is to be found" ((5) Rejfek v. McElroy (1965) 112 CLR, at p 521). Statements to that effect should not, however, be understood as directed to the standard of proof. Rather, they should be understood as merely reflecting a conventional perception that members of our society do not ordinarily engage in fraudulent or criminal conduct ((6) See, e.g., Motchall v. Massoud [1926] VicLawRp 43; (1926) VLR 273, at p 276) and a judicial approach that a court should not lightly make a finding that, on the balance of probabilities, a party to civil litigation has been guilty of such conduct. As Dixon J. commented in Briginshaw v. Briginshaw ((7) (1938) 60 CLR, at p 362; and see, also, Helton v. Allen (1940) 63 CLR, at p 711):

"The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved ..."

clear and cogent evidence to prove matters of the gravity of fraud or crime are, even when understood as not directed to the standard of proof, likely to be unhelpful and even misleading."

I am in no doubt that Ms Chapman consciously lied and misled Mr Bradford in the 000 call in the myriad of ways that I have described in this finding. I have come to this view solely by a process of analysis of the evidence. Her affect was most unusual and disconnected. In such an utterly crucial telephone call, she clearly wanted to portray Lennox as already being deceased, when he was still alive and breathing. I do note that Dr Kirkman, in listening to the 000 call, said that Ms Chapman’s responses were not those of someone who is "actively psychotic". He indicated that a person in a distressed state does not usually have the presence of mind to lie. Her lies would imply a presence of mind that was not in keeping with the situation as she presented it. I am reinforced to a degree in my conclusion by Dr Kirkman’s comments. Her lies represent a state of mind consistent with her covering up having already deliberately harmed Lennox or an intention to harm him or further harm him whilst on the 000 call. They are not at all consistent with a distraught mother having found her infant deceased in its cot.

On the balance of probabilities, this child’s cessation of breathing, during the period after his last cry and before the arrival of Mr Chapman/ambulance officers, was the result of his breathing being intentionally interfered with by the actions of his mother, either using her hand or possibly soft material. No other individual was present. The fact that there are no marks on Lennox’s mouth, face or neck is not determinative of whether there was an act by Ms Chapman of stopping this child breathing. I note the evidence of Professor Byard and Dr Donald that asphyxia can occur with only mild pressure for short periods of time perhaps between 30 seconds and a minute.

The fact that Ms Chapman reported the presence of blood to both Mr Chapman and the ambulance officer whilst Lennox was still alive is of some importance. However, the unchallenged expert evidence of Professor Byard and Dr Donald is that Lennox may well have suffered some sort of respiratory episode by way of a partial asphyxiation which might well have produced bloody fluid or frothy fluid from his mouth and nose but from which episode a child is capable of recovering.

In other words, the presence of blood prior to and at the time of the cries heard on the 000 recording are not inconsistent with Lennox being alive at the time of the cries that we hear. It is likely to have been so present when reported by Ms Chapman. It is an unusual thing to invent – especially for a lay person untrained in pathology. We cannot reliably know how long before Lennox is heard to cry such blood may have been present or then with certainty what caused it.

It is possible that it resulted from co-sleeping. However more plausible is a prior deliberate attempt to stop his breathing from which he survived. This may explain the different versions given by Ms Chapman of deliberately smothering Lennox. This might also explain the prior removal of jumpsuit with the blood on it and putting it in Lennox’s room. In this regard I accept the evidence of Mr Chapman that Lennox was clothed in a singlet and nappy only when he came home. He said he had a vivid recollection of seeing him and thinking how cold he would be on the tiled floor. Further there was no evidence of or plausible reason for any person on the scene to place the jumpsuit in Lennox’s room in such an emergency situation. I have previously observed the likelihood of Lennox being exposed to serious risks of drowning and also accidental suffocation in a bed within a few hours whilst at home with a parent is low. It is possible that Ms Chapman deliberate submerged Lennox in the bath when she could not cope with his crying.

I cannot make a positive finding upon the evidence that Lennox suffered a prior deliberate attempted asphyxiation. However, I find by the presence of blood and Dr Donald’s evidence, Lennox did suffer an event that compromised his breathing. However, Lennox recovered from it. I accept Dr Donald’s evidence that red fluid could still be emitted for some time afterwards.

In any event, whether there was blood present or not when Ms Chapman reported it, Lennox was alive subsequent to that report is evidenced by his healthy cries.

I find that an external event must have occurred to cause his death prior to the arrival of the ambulance officers and/or Mr Chapman and after his cries. An intentional stopping of this child’s breathing by Ms Chapman is the only scenario that can be considered to be realistic.

As detailed throughout this finding, there are other cogent pieces of evidence which support that Lennox was deliberately smothered by Ms Chapman.

Firstly, there is evidence of the severe mental disturbance of Ms Chapman by the time that Lennox died. Whether she suffered a depressive disorder or was in a state of extreme anxiety, her mental health was severely compromised. . The existence of psychotic or pseudo-psychotic symptoms relating to Lennox is evidenced by the evidence of Mrs Pisano. Importantly, these were reported to have happened before Lennox’s death.

There is also abundant evidence that Ms Chapman was excessively concerned that Lennox was not normal and that she had damaged Lennox and that he would suffer from some sort of mental impairment as evidenced by his ear condition. It is noted that no reassurance from either GP’s, child health nurses, her mother, her husband, Dr Kirkman or anyone else would dissuade her from that overwhelming concern that Lennox was not right mentally and that he would be handicapped or disabled somehow – probably as a result of her own actions whilst Lennox was in utero.

She was having difficulty "coping" with Lennox. She had had little time to herself alone to care for Lennox and the vast majority of her care of Lennox had been done either jointly with the husband, mostly by the husband, or by her with the support of family members such as her own mother, her father, her step-father and members of Mr Chapman’s extended family. She could not bond with Lennox, although he was very much a wanted baby.

Importantly, there is reliable evidence given by Mrs Beverley Chapman, the paternal grandmother, of an incident of very rough and even "angry" handling of this infant in the week before his death as referred to above. This shocked Mrs Chapman. When examined about that Ms Chapman did not deny that such an incident may have taken place and indeed offered to the court that if Mrs Chapman said that it had occurred in the way she did that must be correct. This was obviously a very disturbing incident. It was not a momentary incident of annoyance.

It is also to be noted that Ms Chapman advised that on the night prior to Lennox’s death she had had a "terrible night" and was simply tired.

She was also physically very unwell as a result of the retained placenta and the infection which followed that. The pressure that that would place on a sick, and majorly depressed mother, must be considered to be enormous.

Ms Chapman was "delicate" psychologically and who did not deal with stressful situations in her life well. There can have been nothing in her life as stressful as having this child with her insistent belief about him being "damaged" and the pressure of not only "coping" with such a child then but also through his life.

Finally, I am of the view that Ms Chapman’s accounts of the intrusive memories of deliberate smothering should be given some real weight for the reasons discussed and in line with Dr Kirkman’s opinion. The objective evidence bears out intentional harm. The flashbacks experienced then would represent what actually happened. I acknowledge that the court should be very cautious as to Ms Chapman’s reliability of reporting how Lennox died.

I have considered all evidence carefully. I have been greatly assisted by Mr Brown. I bear in mind the principles applicable to the standard of proof in light of the gravity of this matter.

I am satisfied for the reasons given that Lennox’s death was caused by his respiration being stopped by the intentional actions of Ms Chapman during the period after his last recorded cry and before Mr Chapman’s arrival at the home.

Ms Chapman’s intentional actions causing Lennox’s death were not rational or the product of a sound or balanced mind.

System Issues

A large portion of the evidence at inquest concerned the quality of the treatment and support received by Ms Chapman during Lennox’s life. I have already set out the evidence as to the services and practitioners that assisted Ms Chapman, and the nature of the treatment and assistance.

I note that the quality of the obstetric treatment of Ms Chapman pertaining to her retained placenta was not the subject of any detailed evidence; and Ms Chapman’s counsel appropriately did not seek to make it an issue on the inquest.

Apart from Ms Chapman’s treating doctors, representatives from the Child Health and Parenting Service (CHPS) and the Adult Community Mental Heath (ACMH) team were thoroughly examined by Mr Brown. The notes made at the time of visits were tendered into evidence. Mr Brown explored with all witnesses in this category whether any further actions could reasonably have been taken that might ultimately have supported Ms Chapman and prevented Lennox’s death.

Firstly, I find that the quality and extent of support received by Ms Chapman by both ACMH and CHPS was high and in accordance with their guidelines. The recording of visits and actions by both organisations was extensive allowing me to ascertain the content of the visits. In respect of CHPS I find that the weekly nurse’s visits to Ms Chapman exceeded the average, in recognition of the high level of Ms Chapman’s needs. Similarly, Ms Chapman had the benefit of a psychiatric registrar as part of the ACMH visit, as well as the dedicated follow-up described by Ms Joyce, until Dr Kirkman’s treatment commenced.

Dr Kirkman himself made efforts to provide Ms Chapman with longer consultations than normal and with weekly follow up, albeit clearly he had a voluminous workload being the only private psychiatrist on the North West coast with a population of 125,000 people. In that regard he stated that the typical population ratio is one psychiatrist for 11,000 people. Hobart for example has 20 psychiatrists in private practice for twice the population of the North West coast.

Ms Chapman’s general practitioner, Dr Wild, saw Ms Chapman on 17 November but did not turn his mind to the issue of a mental health plan for her, despite her concerning situation, as she was to be under the care of her psychiatrist. In this regard Dr Wild stated, when asked why not:

"I guess I was the second line doctor in this situation as well. She’d already seen Dr Dowd (sic) who had done a referral and respecting his experience, what comes with that is he would’ve done an assessment obviously looking through his brief notes, that he may not have done a formal screening say tool, we call them, an assessment, a list of questions to sort of assess severity."

Whilst not guaranteed, the devising of a formal mental health plan may have been a central focus for various agencies and services to assist Ms Chapman in a united way.

Whilst all of the above performed their duties appropriately it was clear to me that communication between each was lacking so that a fully co-ordinated approach to Ms Chapman’s care could be devised. This was clearly what was needed in such an obvious case of a new mother who was very ill and seriously mentally troubled.

Dr Kirkman did not receive or request any information from ACMH or CHPS that would have given him a breadth of knowledge from professionals about the extent that Ms Chapman was unable to cope. The presence of Mr Chapman in consultations marked that inability to some extent. Dr Kirkman could have requested that material, with Ms Chapman’s consent, but that he did not do so. However, I do not consider that Dr Kirkman’s treatment in the case of Ms Chapman would have been different if he had that information.

Likewise the evidence was that such a document or report could have been sent by the Adult Community Mental Health Service Team who assessed and medicated Ms Chapman to Dr Kirkman even if he had not requested it. I make the same comment about the CHPS notes. Those notes contained detailed descriptions of Ms Chapman’s difficulties written by a professional nurse. The information is valuable if used in a holistic approach to support and treatment.

On the evidence there was no reason why ACMH had to withdraw from active visits.

It is apparent that some treaters in this case were unaware of the services available; for example, Dr Ian Wild and his surprising evidence that Ms Chapman had been referred to Dr Kirkman "and his multi-disciplinary team" when such a team simply did not exist. The role of the general practitioner is vital particularly in a region so lacking in mental health services. To arm the general practitioners with important information to assist their patients should be a priority.

The provision of "hand over" reports to subsequent treaters would therefore not only be capable of providing more information about a patient, their history, and their situation of which they might be unaware, it would also necessarily act as a means of alerting those involved to services which might be available to a client for treatment and support. In this case services such as the Mersey Leven Family Day Care Service might well have been a service which would have helped this family during the period of Mr Chapman’s return to work. However, I am satisfied that Mr Chapman would not have been receptive to the service.

Ms Sue Nesham, Senior Social Worker with ACMH gave the following evidence at inquest:

"So you made the – you formed a professional judgment at that time that at that juncture the Mersey Leven service wasn’t the appropriate service?.....No I thought that that would be a really good service but Geoff said that he wanted it to be his family and friends. Now I don’t know what everyone else thinks but one of the things that we have to do is we have to assess that person’s capacity to make the best decisions for their baby. I felt that he would be making the best decision for the baby. That he was an experienced dad and someone who was obviously a very caring dad and who had stepped in to that role of primary carer for Lennox. And there was nothing to indicate that he wouldn’t make the best choices for his baby. And I mean I use my parents and parents in law to look after my children. They didn’t go to child care. So I mean people have the right to make those sorts of decisions. And there was nothing to indicate that he wouldn’t make those sort of decisions."

Ms Sue Nesham was asked to visit Ms Chapman in her home to determine child protection issues. I make no criticism of her decision not to make a referral. Mr Chapman was clearly a devoted, caring father and inspired the trust in all those who assessed the situation. He portrayed that he had the resources of family and friends to help. As such Lennox was not a child that would have been perceived "at risk". For the same reasons I make no criticism of all other persons who were in a position to consider a Child protection referral but did not.

A co-ordinated approach to the situation by all services involved may have been more persuasive to Mr Chapman in allowing home care. He certainly would not have allowed an admission to Spencer Clinic or the Mother and Baby Unit in Hobart. Both Mrs Chapman and Mr Chapman were generally unwilling to engage the services that were offered to them by the State.

I find that the treatment and care provided to Mrs Chapman was appropriate in all of the circumstances. The services referred to were diligent, suggested solutions and made themselves accessible.

Ultimately, only admission to a local Mother and Baby Unit would have been palatable to both Mr and Ms Chapman.

In the confines of the treatment/assistance that would be accepted by the Chapman family that the State and its agencies acted appropriately in all of the circumstances.


1. That there be established a protocol whereby "handover" documents (including copies of progress notes) or a report be automatically sent by the Adult Community Mental Health Service Team/CAT Team to any private general practitioners, psychiatrists or psychologists who assume responsibility for a former Adult Community Mental Health Service/CAT Team patient.

Mr McKee advises that steps have been taken to facilitate the provision of documentation between the Department and private general practitioners, psychiatrists or psychologists who assume responsibility for former adult Community Mental Health Service patients. I encourage the development of a workable and ongoing arrangement. I also encourage private practitioners, where appropriate, to make contact with appropriate public services for the benefit of their patients; and where possible provide patient information to assist those services in the care of the patient.

2. I recommend that a "Mother and Baby Unit" (or a facility for hospital beds of that type) be established in the north and north-west of the State.

The evidence of Dr Kirkman was that such a service exists in Tasmania, but in Hobart only. There are a limited number of beds in that facility and only a small number of those are publically funded and available to those who are not privately insured or who do not have the ability to pay privately themselves.

Dr Kirkman offered such an admission to this family and they refused it. I refer to my above comments on that evidence.

To relocate a mother and child by as much as 400 kilometres from their home is a disincentive to people who require such an admission. Patients are necessarily removed from their families and local support networks if they wish to utilise that service. Such relocation might in many ways be counter productive to the objectives of the admission.

I do not necessarily recommend that an extensive "stand alone" institutional facility should be constructed or established. Dr Kirkman’s evidence was that if three beds were available on the north-west coast for this purpose that is likely to meet the community’s need in this regard. Such a facility would be an important adjunct to a neo-natal or maternity unit in Tasmania’s major regional hospitals.

Had such a facility been available in this case it would necessarily have presented as a far more palatable option to this family. Such a unit does have the stigma attached to it of being a "mental health facility" that the Chapman were intent upon avoiding. It would allow Ms Chapman and child to be together at a critical time and to allow both of them to be helped and treated.

Dr Kirkman gave informative evidence to the inquest to the effect that maternal mental health services on the northwest coast are most inadequate. He said:

"I gave a lecture to the mental health clinicians of the North West Coast about six weeks ago on maternal mental health which is disorders of pregnancy and in the post-partum period, and that evolved into a broad discussion about the provision of mental health services and really that there is not only a lack of in-patient beds for mother and babies but really there is no co-ordinated maternal mental health service at all."

Further Dr Kirkman said:

"….and I think that would’ve been acceptable to Geoff and Katrina, if I’d been able to say look I would like you to come into the North West Private Hospital, there is a bed there for a public patient, that’s funded by the State Government, you can be here locally, I think they would have taken it."

In his final submissions to the inquest, Mr McKee submitted that the State recognises the need to provide appropriate services to mothers and babies on the North West Coast; and that the Statewide Mental Health Services Steering Committee for Perinatal, Maternal and Infant Mental Health Services is currently considering this issue.

Mr McKee submitted that "the work of the Steering Committee is ongoing and that it is envisaged that a public announcement regarding the delivery of perinatal, maternal and infant mental health services on the North West Coast of Tasmania will be made at a future time when all planning has been completed." 

3. I recommend that guidelines be developed to ensure a full and free exchange of information amongst those services and persons involved in treating and assisting those new parents and infants that require a high level of support and multidisciplinary approach.

Many government services have knowledge of families with newborn infants who may be in difficulty. It is important that those services meet or exchange information in some simple and relatively informal way so that those who have information about families in distress have an enhanced ability to assist. Such a procedure or mechanism need not involve any elaborate organisation. It may be in the form of regular meetings or even the exchange of information, perhaps by email, amongst these organisations.

Organisations such as the Maternity Units at hospitals, the Adult Community Mental Health Service, the Crisis Assessment Team, Child Health Nurses, Child Protection Assessment Units and other similar entities ought be represented at such a meeting or be able to "pool" information regarding families in this situation.

Before information regarding families could be disseminated the parents involved would need to provide consents to the sharing of information. However, on the evidence it is apparent that many, if not most, families are content to do so. The evidence from Child Health Service indicates that client consent to provide information to other services is readily given.

4 That the State Government provide funding to "SIDS and Kids" to educate the community in relation to "safe sleeping" practices for newborn infants.

It is appropriate that I make such recommendation notwithstanding having found that the ultimate cause of Lennox’s death was an act of suffocation by Ms Chapman, rather than an unintentional overlay. As previously noted Ms Chapman had previously taken Lennox into her bed to sleep contrary to safe sleeping recommendations. Further, I have not been able to rule out the distinct possibility that on the day of Lennox’s death he suffered a partial suffocation from which he survived as a result of sleeping with Ms Chapman.

Ms Chapman was extremely anxious and therefore unlikely to take in information such as "safe sleeping" advice properly or at all. This case underlines the need to educate the community and reinforce that education.

Evidence was given to the inquest by Mrs Leanne Raven, 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.

Ms Raven also gave evidence about the prevalence of sudden infant deaths in Tasmania and nationally. It is apparent that the numbers of deaths in this jurisdiction of this type has stabilised in recent years and not improved significantly over that time. Alarmingly, there have been 6 infant deaths since October 2010 that have occurred in circumstances where the infant has been co sleeping with a parent or died in circumstances where all safe sleeping practices were not observed.

Mrs Raven gave evidence that if funding were available to provide educators in the community those educators could provide a "train the trainer" program which would necessarily multiply the ability for the "safe sleeping" message to be disseminated in the community .

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 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 specifically considered my previous recommendations to assist with funding for an educator employed by SIDS and Kids. I have now made the recommendation in several findings over a three year period. 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 statewide 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.

Since the death of Lennox, Mr Chapman has been committed to raising funds for the SIDS and Kids organisation. He stated that he has held three fundraising events, two of those being tattoo shows. Each tattoo show has raised about $2500 for SIDS and Kids. His efforts and commitment to this cause are admirable; and no doubt will greatly assist such an important organisation.

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: Friday 3 June 2011 at Hobart in the State of Tasmania. 


Olivia McTaggart