Record Of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of
An Infant
Without Holding an Inquest

Find That:-

The infant died in 2006, in Glenorchy and was aged 6 months.

I find that the infant died as a result of sudden unexpected death in infancy while co-sleeping with an adult.

Circumstances Surrounding Death :-

The infant was born in the Royal Hobart Hospital ("the RHH") in May 2006.

During the mother's pregnancy and after the death of her partner, the mother came to the attention of medical authorities because of her psychiatric state. When she was 20 weeks pregnant she was admitted to the RHH's Department of Psychological Medicine ("DPM"). A diagnosis was made of alcohol abuse and personality disorder. She was an inpatient for three days and discharged after follow-up was organised with her general practitioner and the Antenatal Clinic. In March 2006 the mother was assessed by consultant psychiatrists at DPM at the request of Dr Stephen Raymond from the Department of Obstetrics at the RHH. She was found to have substance abuse problems and personality and situational difficulties but no psychosis or major depressive illness. She was offered admission to DPM but declined. The risks of medication and substance use on the developing foetus were discussed with her. She wished to continue her then current medication of Citalopram (40mg daily) and Diazepam (30mg). A request for additional medication was declined.

At 9:00am on the day of the infant's birth, the mother reported to midwifery staff that the baby had fallen from the bed overnight. She stated that she had been feeding the baby in bed and had woken to find the baby crying on the floor. This disclosure prompted a full assessment of the infant for injury but none was found. At this time the mother was given clear instructions not to feed the infant in bed nor to co-sleep with her. She was advised to wean her medication.

In May a social worker at the RHH attended the mother to discuss the incident earlier that day. It was explained that the mothers level of medication was of concern. The mother agreed to reduce her medication but only after she returned home. On the following day a notification was made to the Child Protection Advice and Referral Service ("CPAARS") because of concerns arising from the incident the previous day.

In May 2006 the infant was found by nursing staff crying on the floor beside the mother's bed. The mother was asleep and when woken had no recollection of how the infant could have come to be on the floor. The infant was cold with a temperature of 36.4 degrees. She was admitted to the special care nursery of the Neonatal Intensive Care Unit for observation. A drug withdrawal observation chart was commenced but no symptoms of withdrawal were detected. An examination of the infant was normal and she was observed to feed and settle satisfactorily.

Over-sedation of the mother was considered to be a contributing factor in the two instances where the infant fell onto the floor. Consequently her medications were again reviewed by the RHH's obstetric and psychiatric teams and the mother was kept under observation for signs of over-sedation and to ensure that she was well enough to resume supervised care of the infant. The mother received counselling and a social worker together with a High Risk Infant Care Nurse co-ordinated plans for the support and care of the mother and infant post-discharge.

CPAARS was notified of the infant's second fall. To that date it seems that it had not acted on the notification made 4 days earlier. This time CPAARS rated the notification Priority 2 and it was referred to the Child Protection Service for investigation and assessment. It also proposed that a case conference be held at the hospital that same day to be attended by all services working with the family. However, it seems that such conference did not occur nor was the investigation and assessment undertaken before the infant was discharged from the RHH with her mother.

CPAARS records indicate that at this time it was aware that the mother was having difficulties coping with the suicide death of her partner and that she was over-using valium. It was also aware that her inappropriate use of medication was the likely factor causative of the infant two falls whilst in hospital. Nevertheless, it was determined that the infant was not at immediate risk of harm because the mother had access to family help, notably her mother, who had indicated a willingness to stay at the home when required and to monitor the situation. It seems that it was on this basis that the infants notifications were placed on the unallocated cases list.

I need at this point to explain the unallocated list. It is my understanding that upon a child being notified to the Child Protection Services an initial assessment is undertaken to determine whether the matter requires protective investigation and if so, its priority. When a notification is assessed to require investigation but its priority is not immediate, (ie. It is classified as a Priority 2 and not a Priority 1 Notification) that matter is placed on the unallocated list pending its allocation to a child protection worker who then undertakes the protective investigation. Whether that allocation and investigation takes place is dependant upon the availability of departmental resources.

I understand that during 2006 in excess of 700 notifications had accumulated on the unallocated list at the Southern Child Protection Service Centre. I understand further that the Child Protection Service did not have the resources to manage that number of notifications with the result that many, including those concerning the infant, were unlikely to be acted upon.

In June 2006 Family Child Health Nurse, Ms Elaine McCallum from the Family Child and Youth Health Service ("FCYHS") made a home visit. The infants grandmother was present. She was staying with her daughter to help care for the children. The grandmother reported to Nurse McCallum that one morning she had heard the infant crying. She had gone to the bedroom where she found the infant in bed with her mother who was asleep. It was noted that bedding was partially covering the infant's head and that she was very warm as the electric blanket was on. The infant was taken into the lounge room by her grandmother where she was cooled and settled. At this visit it was also disclosed to Nurse McCallum that the mother was continuing to take valium and that she had been using cannabis. As a result of these disclosures Nurse McCallum counselled the mother upon Sudden Infant Death Syndrome and in particular reminded her of the increased risks associated with co-sleeping and the use of prescribed and illicit drugs. Following this visit Nurse McCallum made a report of her concerns to CPAARS. It considered that this notification did not indicate a significant increase in the risk of harm to the infant thereby warranting an upgrading of her prioritisation. In the result it remained on the unallocated cases list. However, it understood that Nurse McCallum would continue to visit the household on a weekly basis.

In June 2006 two follow up visits were made by FCYHS to the family home. On the latter occasion there were concerns that the mother was unresponsive to her own medical needs. It was recommended that she receive help, mainly counselling, from the Parenting Centre. There was a further follow-up visit on 6 July. On this occasion the mother was low, sad and upset. She reported that she had an appointment to see her doctor later that day. She was again advised to accept help from the Parenting Centre.

In July, the mother was admitted to the DPM and treated for possible suicide thoughts and drug and alcohol dependency.

On 17 July CPAARS was notified of an alleged suicide attempt made by the mother, her hospitalisation for alleged misuse of drugs and a possible inability on her part to care for her three children. This notification was allocated a Priority 1 rating and referred for immediate investigation and assessment. At this time CPAARS was aware that the children were safe and in the care of their maternal grandmother.

On 18 July Child Protection workers attended the home along with members of Tasmania Police. The mother explained that she had voluntarily admitted herself to DPM because she had become addicted to alcohol and valium following the death of her partner. However, she did not consider that she required drug and alcohol counselling as she believed she could deal with these issues on her own. The mother stated that she was receiving support from her family, principally her mother, and also from the Glenorchy Family Day Care Centre Program. The Child Protection workers assessed the situation as calm and that the mother had adequate support. There was no indication that she was suicidal. Overall they concluded that there was no immediate risk to the children and the notification was placed on the unallocated waiting list for further follow up. It needs to be noted that at the time of this visit the grandmother was not present and was thus unable to indicate the level of support that she was able to continue to provide to her daughter. It should also be noted that the Child Protection workers did not observe either the infant or her brothers during their visit.

On 19 and 20 July 2006 CPAARS were informed of an individuals further concerns for the welfare of the infant and her brothers and the mother's capacity to care for them but no action was taken in response to this information. On 2 August the mother was visited by an officer from Family Child and Youth Health Services ("FCYHS") for the purposes of undertaking a postnatal depression screening. The screening score was 14 which obligated FCYHS to ensure that the mother had adequate support in place. In this regard the visiting officer encouraged her to maintain her doctor's appointments and to make contact with a social worker at Glenorchy. It seems that nothing further was put in place to monitor or review the mother's condition.

In November 2006, the mother was at home when she was visited by friends. They had brought some alcohol with them. The infant had been put to bed at around 7:30pm. She had been suffering from a cold and because of this her mother placed her in her own bed rather than the infants bassinet. Beforehand the mother gave the infant approximately 1ml of Demazin in an effort to stop her coughing and to clear her nose. During the evening the infant had bouts of coughing and her mother attended and settled her. At about midnight several of the visitors left. However, two others remained and stayed overnight sleeping in the lounge room. The mother went to bed at about 1:30am.

The following morning between 6:30am and 7.30am the mother was woken by her son.  She checked on the infant and found that she was not breathing. She recalls that the doona on the bed was pulled up to the infant's chest and that her head was supported by a pillow. The infant appeared pale and her lips were stiff. The mother ran into the lounge room telling her friends to contact an ambulance as she feared the infant was dead. CPR was commenced and was briefly continued by ambulance personnel on their arrival. However, it soon became apparent that the infant was deceased.

A post-mortem examination was carried out by forensic pathologist, Dr Donald Ritchey. He made specific findings of "Petechial haemorrhages of pleura and thymic capsule." Dr Ritchey's report also incorporates these comments: 

"The autopsy revealed a well developed, hydrated, and apparently well-cared for infant with only non-specific findings (petechial haemorrhages of thymus and lungs). Specifically, there was no evidence of abuse or infectious disease to explain the death. Toxicology testing of post-mortem blood revealed the presence of paracetamol and chlorpheniramine consistent with the history of having been administered liquid Demazin for cold symptoms in the hours before her death. I do not believe that this contributed to this child's death."


"It is not possible, within the current state of medical science, to distinguish death due to the sudden infant death syndrome (SIDS) and suffocation due to compression by an overlaying adult SIDS is defined as, the sudden death of an infant under one year of age which remains unexplained after thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. The autopsy findings in cases of SIDS are variable and non-specific. Petechiae are frequently present on the thymus, pleura and pericardium but neither their presence nor absence confirms or precludes the diagnosis of SIDS. Most recent studies suggest that co-sleeping, or placing an infant in an adult bed, is a potentially dangerous practice."

It is Dr Ritchey's opinion that the infants death should be categorised as a sudden unexpected death in infancy while co-sleeping with an adult.

It is relevant for me to record that in January 2007 the infants siblings were made the subject of a 12 month Care and Protection Order because the mother was incapable of caring for them by reason of her ongoing addiction to prescription medication and alcohol.

Findings, Comments & Recommendations -

I am satisfied that there are no suspicious circumstances surrounding the infants death. I accept the opinion of Dr Ritchey and find that the infant died as a result of sudden unexpected death in infancy while co-sleeping with an adult.

The circumstances of the infant's death give rise to three particular matters which, in my view, warrant comment. They are:

  • The failure on the mothers part to heed the advice given to her to avoid co-sleeping with an infant,
  • The insufficient response of the Child Protection service in the light of the clear evidence that the infant was a child at serious risk of harm and
  • Application of the Perinatal Registry Act 1994 and its amendment.

I will deal with each in turn.

Within the first three weeks of the infant's life there were two incidents involving co-sleeping which threatened serious harm to the infant. The first occurred at the RHH on the day of her birth and the other at home, either on or just prior to 1 June. Following each event the mother was warned of the risks associated with co-sleeping and advised to desist from the practice. It is a matter of very serious regret that she did not heed this advice. Had she done so and the infant was permitted to sleep alone in her bassinet on the night of 11 November 2006 then the likelihood of the infant's survival would have been significantly enhanced.

Findings made by coroners, both in this State and elsewhere have repeatedly warned parents that sharing a bed with an infant markedly increases the risk of death, either by Sudden Unexpected Death in Infancy, Sudden Infant Death Syndrome or by fatal sleep accidents including overlaying of the baby by another person, entrapment or wedging or suffocation by bedding. The risk of an infants death is heightened when the co-sleeper is a smoker and/or is affected by alcohol and/or drugs causing sedation. The infants tragic death provides another opportunity, firstly to remind parents of the very real perils of co-sleeping with an infant and secondly to point out to the public health authorities that there remains, in some sectors of the community, an ignorance of the risks associated with co-sleeping and hence the ongoing need for a public awareness programme.

There were during the infant's short life a series of red flag events which, in my view, clearly identified her to be a child at risk. These started with the two incidents in hospital occurring over 3 days when the infant was found on the floor beside her mothers bed. Then, less than 3 weeks later the infant was "rescued" by her grandmother in a co-sleeping incident. These matters were all notified to CPAARS which at the same time was aware, or should have been aware, that the infants father had suicided before her birth, that as a result the mother was psychologically fragile and that she was having alcohol and drug problems which she seemed reluctant to address. Despite these circumstances CPAAS did not consider the infant to be at immediate risk of harm and that it was sufficient for her to be placed on the unallocated list. This remained the situation until mid-July when CPAARS learned of the mother's hospitalisation. This prompted a visit by Child Protection workers to the family home where they again satisfied themselves (without observing any of the children) that neither the infant nor her siblings were at risk of immediate harm. The infant remained on CPAARS unallocated list and it seems that it had no further involvment with her up to her death less than four months later. This brief summation leads me to make these comments:

  • In 2006 the unallocated list represented a "black hole" where notifications which had been assessed as requiring investigation were unlikely, because of a shortage of resources, to ever be re-visited. By assigning the infant's case to the unallocated list the child protection authorities were effectively abandoning any further investigation of the infants circumstances and the implementation of any plan to protect the infant which that investigation may have revealed as necessary for her safety.
  • Had the infant's circumstances been properly investigated at the time of or shortly after the earlier notifications it would have been clearly evident that she was a child at risk and that a plan needed to be put in place to better ensure her protection. That plan necessitated, in the very least, a schedule being laid down for the monitoring of the infant's care at regular intervals. Too, it required conditions being imposed upon the mother obligating her to undergo treatment for her illnesses and permitting her treaters to report upon her progress.
  • The assessment of the infant's circumstances made by the child protection officers in July 2006 was inadequate. It appears that it involved an interview with the mother and nothing more. None of her assertions, it seems, were corroborated. The children were not observed. No contact was made with the grandmother to assess the ongoing level of assistance she was able to provide. No attempt was made to obtain from the mothers medical treaters their advice upon the state of her psychiatric health, the degree of her dependence upon alcohol and drugs, the steps in place to reduce any dependence and her capacity from a medical viewpoint to adequately care for the infant and her siblings. Too, it seems that no independent enquiries were made of other agencies or service providers to establish the assistance available to the mother and whether she was utilising that assistance.
  • Had a more comprehensive investigation been undertaken in July 2006 it would have, in my view, been abundantly clear that the mother was continuing to struggle with her psychiatric and addiction difficulties which she was reluctant to address and which were compromising her capacity to ensure the infants safety. These circumstances made it, in my opinion, inappropriate for the infant to remain on the unallocated list and thus be ignored. Instead it necessitated the implementation of a protection plan incorporating those features which I have described above.

I am unable to make a positive finding that the infant's death would have been avoided if CPAARS had acted in the manner which I have suggested. Nevertheless, it is my view that such action, particularly if it had been taken at the earliest opportunity, would have markedly increased the likelihood of the infants survival.

It is clear upon the evidence that the Child Protection service was, in 2006, inadequately equipped and resourced to properly deal with all those notifications which had been assessed as requiring investigation. This was a most regrettable state of affairs. It meant that vulnerable infants such as the deceased were denied that level of State protection which their domestic situation required. I am informed that since infants death additional resources have been allocated to the Child Protection Services and protocols have been put in place to manage the unallocated list so that all notifications are allocated and investigated within set time frames. It is my recommendation that there be a regular audit of the unallocated list against those timeframes.

My next comment relates to the Perinatal Registry Act 1994. ("the Act") The Act provides for the establishment of the Council of Paediatric Mortality and Morbidity. ("the Council") A principal function of the Council is to investigate the circumstances and the conditions which may have caused the deaths of children in Tasmania in the age group from 29 days to 17 years. In the course of my investigation of the infants death it came to my notice that a sub-committee of the Council had undertaken an investigation into the deaths of several children who had come to the attention of the child protection authorities. Apparently, the investigation was focussed on whether any failings of the States child protection system had played a contributing role in the death of and the other children. That committee has produced a report, copies of which have been provided to the State Director of Children and Family Services and to the Commissioner of Children. However, my request that a copy be provided to myself along with recommendations specific to the infant has been refused by the Department of Health and Human Services, relying upon s15(1) of the Act which specifically prohibits the disclosure of any information or the publication of any document acquired by any person as a member of the Council or of a committee of Council.

It is, in my opinion, most regrettable that a coroner, having a statutory obligation to investigate the cause of a persons death and to make recommendations upon ways similar deaths may be avoided is denied access to material which is directly relevant to those matters. This is particularly concerning when the death involves an infant who is dependent for its safety upon the quality of care provided by its guardians, including the State. These matters lead me to recommend that, as a matter of urgency the Act be amended so that a coroner may be provided with any information or documents held by the Council or a committee of Council which touches upon or is relevant to the death of a child who is the subject of a coronial investigation. It is pertinent to note that s15(1), in its present form, already permits Council to release such material to a doctor or nurse in certain specified circumstances and to persons connected with research.

Following completion of the investigation undertaken by the Councils sub-committee the Department of Health and Human Services released to the public-at-large a document incorporating some general recommendations. Several of them are relevant to the circumstances of the infants death and hence, its appropriate that I set them out here. They stipulate that the Child Protection Services:

  1. Mandate the requirement that no priority one child protection assessment is to be completed and/or the file closed, without the subject child(ren) being sighted by the child protection officer responsible for the decision.
  2. Facilitate ways to obtain formal input from professional experts in the relevant field to assist with decision making in complex cases where neglect, bonding/attachment, drug and alcohol, disability, neurodevelopmental or mental health issues are factors.
  3. For cases involving an overlap of services, establish formal pathways for liaison between Child Protection Services and Mental Health Services, Alcohol and Drug Services, and Disability Services at a state, area and local level.
  4. In cases where services other than Child Protection Services are monitoring and providing support,……develop a formal protocol and pro-forma to make explicit the expectations on each service. Implement a process where roles and expectations are formally discussed, documented, acknowledged and accepted.
  5. Develop a process for Child Protection Services to provide written advice to caregivers detailing the conditions which need to be fulfilled in order to prevent further action/ intervention from Child Protection Services.

I adopt and support each of these recommendations.

I conclude by conveying my sincere condolences to the infant's family.


DATED : Friday, 11 December 2009 at Hobart in the State of Tasmania.


Rod Chandler