Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Christopher P Webster, Coroner, having investigated the death of

 An infant


I find :

that the deceased died as a result of Sudden Infant Death Syndrome (SIDS) while bed sharing.


The infant death was reviewed by the Paediatric Mortality and Morbidity Sub-Committee. All cases of infant deaths which are reported to this office are reviewed by this committee prior to the conclusion of the matter.

The Committee have expressed concerns regarding the number infant deaths involving unsafe sleeping environments, in particular where the infant has been co-sleeping with one or both parents. While bed-sharing is common it has been associated with sudden infant deaths.

SIDS recommendations, endorsed by the Royal Australian College of Practitioners and the “Sids and Kids Safe Sleeping Program”, advise that there is an increase in risk where a infant or toddler bed sharing with an adult may get caught under bedding or between the wall and bed, fall out of bed or are rolled upon by someone who sleeps very deeply or is affected by drugs or alcohol, or their mothers smoke. This also extends to bed sharing with other children or pets. There is further risk involved where the infant was born pre-term or is small for its’ gestational age.

The current recommendations are that infants should not share a bed surface with a smoker; where there is adult bedding, doonas or pillows; where the baby can become trapped between the bed and a wall, can fall out of bed or be rolled upon; where the parent/adult is under the influence of alcohol or drugs that cause sedation or is overly tired; where infants are sharing bed surfaces with other children or pets; and advise against placing a baby, to sleep, on a sofa, beanbag, waterbed or sagging mattress.

Whilst bed sharing is considered appropriate when feeding, cuddling and playing an infant should always be returned to their own safe sleeping environment prior to the parent/s going to sleep. Infants should always be supervised when placed on raised surfaces that do not have the restrictive rails similar to that of a cot.

It is particularly poignant, with the onset of winter that parents are of the mistaken belief that the infant is cold and places the infant in bed with them to keep them warm. In these cases it is possible for the infant to become over heated. The infant is best left in their own bedding with appropriate blanketing and possibly a hat to prevent the escape of heat via the head.

I find that death was due to SIDS while bed sharing.

DATED : Thursday, 20th April 2006 at Hobart in the State of Tasmania.

Christopher P Webster