Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Olivia McTaggart, having investigated the death of the "baby P"


These findings have been partially de-identified in relation to the name of the deceased by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995

I have decided not to hold an inquest into the death because the investigation into the death has sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

Having conducted an investigation I do not consider that the holding of an inquest would elicit any significant information further to that disclosed by the enquiries conducted.

Find That:

(a) The deceased died on or about the 25 February 2011 at  St Helens.  

(b) The deceased was born in Launceston in  January 2011 and was aged 1 month.

(c) I find that the deceased died as a result of unexpected death in infancy whilst co-sleeping with his parents.

Circumstances Surrounding the Death:

The deceased was born in January 2011.  The deceased was a happy and contented baby who would generally wake about twice a night to be fed.  He had suffered some minor ailments but otherwise he was developing well. His mother and father have two other sons, aged 2 years and 3 years at the time of the deceased’s birth.  The family were experiencing financial difficulties and were surviving on Centrelink benefits. One of the older children was receiving regular treatment in Hobart for a cleft lip and palate. This treatment added to the stress upon the family.

Both his mother and father were smokers. The deceased’s mother reduced her smoking during her pregnancy. She did not drink alcohol whilst she was pregnant but did smoke approximately 10 cannabis cones a week. The deceased's father smoked around 10 cigarettes a day and consumed alcohol regularly.

On 24 February 2011 the deceased's mother took her baby to the Child Health Centre at St Helens for his 4 week check-up. Both mother and child were diagnosed with thrush and were put on Nilstat.

Late that afternoon the deceased was given 1ml of Nilstat prior to being given his formula.  The deceased mother indicates that the deceased was unsettled after his feed. At about 2am the following morning the deceased’s mother gave the deceased a further bottle of formula. He was placed in his bassinette.  A short time later the deceased's mother removed him from his bassinette and took him to bed with her. She then breast fed him and he then fell asleep. The deceased's mother laid the deceased in her bed between her partner and herself.  He was laid partly on his back and side. The deceased was wearing a jump suit over a short body suit and a disposable nappy. The doona on the bed was not covering the deceased when he was put to bed. Before going to bed the deceased’s mother had smoked about two cones of cannabis and the deceased father consumed 6-7 beers.

When the deceased's mother woke up at about 6am the deceased was laying on his back with his palms out next to his head.  He was not breathing. The doona on the bed was about at the level of his chest. The deceased’s mother shook the father and said ‘he’s not breathing!’. The deceased father ran outside and yelled out for help. The deceased mother started CPR using two fingers. The deceased father managed to contact his neighbour. The neighbour  ran next door and entered the kitchen. The deceased’s mother approached him with the deceased in her arms.  She stated, ‘help me he’s not breathing;  I’ve tried but he’s not breathing’. The neighbour together with ‘Ms P’ then continued CPR on the deceased. At this stage the ambulance had been called. the neighbour and ‘Ms P’continued CPR for a number of minutes before the neighbour decided to run with the deceased to the St Helen’s hospital. Despite continued efforts to revive the deceased at the St Helen’s hospital he could not be revived.

Forensic Pathologist Dr Donald Ritchey conducted a thorough post-mortem examination of the deceased. He determined that there was no evidence of trauma nor could he determine any anatomical cause of death. Records held by the Child Health and Parenting Service indicates that the deceased was a healthy infant who was developing normally.

Further an investigation conducted by Tasmania Police did not identify any reason for the deceased’s death.  The deceased's mother and father were loving parents who intended no harm to the deceased.

I accept Dr Ritchey’s conclusion that the deceased’s death should be described as ‘unexpected death in infancy whilst co-sleeping with his parents’.

Comments & Recommendations: 

In a recent finding in relation to the death of an infant in circumstances of co-sleeping, I stated;

“Studies have shown that sharing a sleep surface with a baby increases the risk of sudden unexpected death in infancy. Additionally adult sleeping environments may contain hazards that can be fatal for babies including accidental overlaying of the baby by an adult or suffocation from pillows, blankets or bedding. Sharing a bed with an infant can be particularly unsafe if the parent is affected by drugs or alcohol.

The message promoted widely by SIDS and Kids Australia is not to sleep on the same surface as an infant.

Whilst the SIDS and Kids safe sleeping program has been very successful in reducing the rate of sudden unexpected deaths in Tasmania, these deaths comprise a high proportion of potentially preventable deaths of children under the age of 18 years.’’

In line with Dr Ritchey’s conclusions I cannot find that the deceased would have survived if he had slept in his own bassinet. His cause of death, as opposed to the circumstances of death, cannot be ascertained. However, the fact that he was sleeping in the same bed as his parents, who may have had impaired arousal through consumption of substances, was a significant risk factor in his death.

The deceased's mother and father were in that category of vulnerable parents who would have benefitted by strong and regular reinforcement of safe sleeping practices.  The risk factors involved in this regard were; (a) parental tobacco smoking during pregnancy and in the home after the deceased’s birth; (b) the deceased’s mother cannabis use; (c) the deceased’s father use of alcohol; (d) the family’s poor financial position; (d) the strain of managing other young children, particularly one requiring medical treatment in Hobart and (e) lack of extended family support in the area.

The family had been the subject of only one notification to Child Protection Services (CPS) on 3 March 2008 relating to an incident at the home where the deceased’s father allegedly damaged property. No action was taken by CPS as the future risk was deemed to be “low”. Having viewed the CPS file, I accept that this was an appropriate position to take.

I have also examined the Child Health and Parenting Service (CHAPS) records for the deceased and his mother. This organisation is commonly called the child health nursing service. The deceased’s mother missed the 2 week check but attended the 4 week check on  the day before the deceased’s death. At this check the nurse noted some concerns for the deceased mother being - a previous episode of depression, limited social support, financial difficulties particularly surrounding travel costs for their other child’s medical treatment. General advice regarding SIDS and safe sleeping practices was given by the nurse at this appointment. 

I am not aware of the exact details of such advice. In accordance with practice it should have included advice about dangers of co-sleeping with the infant, particularly after consuming drugs or alcohol. However, I note that the deceased's mother was in a hurry to get home as she had left the other children with a neighbour to the attend appointment. I also note that other important matters were discussed at the appointment. A breast feeding assessment and family assessment also took place. It seems likely that advice on safe sleeping practices may have been lost on this occasion.

It is 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.

As I have stated in previous findings, there is a particular ongoing need for targeting and education of high risk sub-groups in the Tasmanian population, so that important messages for risk reduction in sudden infant death become entrenched.

I am aware that there is currently a Model of Care review occurring within CHAPS that will focus on vulnerable families and children.  The review is working to move the focus from a primary intervention to a secondary intervention, being targeted support for those families who most require support.

The Department of Health and Human Services (DHHS) has also recently developed a “Safe Sleeping” DVD for use by professionals. The DVD is targeted towards those families who are most at risk of co-sleeping with their baby while under the influence of drugs or alcohol. It is an excellent initiative in emphasising to high risk parents the possible tragic consequences of sleeping with their infant whilst they are under the influence of alcohol or drugs. I urge the department to ensure that continued steps are taken to maximise the use of the DVD by appropriate professionals, including CHAPS, when working with vulnerable families.

In previous findings I have recommended that the government provide funding for an additional SIDS and Kids employee, so that the education functions and much needed grief counselling function of that organisation could cope with statewide demand. Such a recommendation remains relevant.

In concluding, I convey my sincere condolences to the family of the deceased.

Dated:  8 day of October 2012 at Hobart in the State of Tasmania.


Olivia McTaggart