Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, have investigated the death of ZAC CAMERON RAINBOW without holding an inquest. I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.

I Find That:

Zac Cameron Rainbow died on the 3 February 2007 at 1/28 Clinton Road Geilston Bay.

Zac was born in Hobart on the 3 March 2006 and was aged 11 months.

I find that Zac died as a result of positional asphyxia due to entrapment between a pram wall and the pram mattress.

At the time of the Zac’s death he was not being treated by a medical practitioner.

Circumstances Surrounding the Death of Zac:

Zac was born to Rachael and Cameron Rainbow; he was an only child and lived all his life at 8 Araluen Street, Geilston Bay.

Zac was given regular health checks and was found to be a healthy baby. He was described as a beautiful boy, a healthy happy child, always smiling. By November 2006 Zac was able to sit up unaided and roll over and manoeuvre himself in different directions including by pushing himself backwards and forwards in a wheeled walker. He had a lot of gum activity from about the age of five months and started getting teeth at about nine months and was provided appropriate pain relief for his teething. He had the usual runny nose and cough often related to his teething and his mother gave him Dimetapp from time to time as recommended by her pharmacist, to assist relieve his symptoms.

Christine Rainbow is Zac’s paternal grandmother and assisted with caring for Zac either in her home or Zac’s home approximately once or twice a week from the age of 3-4 months. However, Zac had not spent overnight with his grandmother very often. When Zac was aged about 8 or 9 months Rachael returned to work on a needs basis as a casual employee. Christine looked after Zac for the majority of the time when Rachael was at work several days in each week.

To assist with the care of Zac, Christine purchased a number of items from eBay which included an “Emmaljunga” pram/stroller.
In January 2007 Zac and his parents went to Sydney for a holiday. Upon their return and for approximately the next three weeks, Zac was unsettled on and off with what appeared to be teething issues. His sleep pattern was disrupted and he never went back to a normal routine and his teething was becoming worse. His parents were becoming exhausted. Zac’s father, Cameron was working long hours as well as assisting with the care of Zac.

On Friday 2 of February 2007 Rachael, together with her mother, made an appointment for her and Zac to see her general practitioner as Rachael was having difficulty coping. Rachael’s general practitioner recommended some respite rest for Rachel and Zac in the Baby Unit at St Helens Hospital. Whilst there was a bed available for Rachael on that day, unfortunately there was no bed available for Zac until the following day. Rachael’s general practitioner recommended she have family support over the weekend. Arrangements were made for Rachel and Zac to attend the hospital on the Monday. Later that day Christine Rainbow observed Rachael crying and in “a terrible state.” Christine offered to take Zac overnight to allow Rachael a rest. Rachael accepted this and she was to stay with her mother for respite.

Christine was aware of Zac’s routine and his medication and she was provided with the Zac’s clothing and other items including his formula, other food, high chair and medication including Panadol and Dimetapp. She was aware that Zac had teething problems and had a cold and was only sleeping in approximately 2.5 hour stints.

Christine took Zac to her home. It is her evidence that during that evening Zac was his happy usual self. She fed him and at about 7pm she bathed him and he went to sleep in his cot in the spare room at approximately 8pm. At about 9.30pm Zac woke and Christine calmed him by wrapping him in his blue rug, placing him in the pram and wheeled it backwards and forwards, and then rocked him in her arms until he fell asleep. She then placed him into his cot.

Zac again woke at 11pm but fell back to sleep without too much difficulty. He woke again at about 1am and Christine was unable to have him settle. Christine put Zac on his side in the pram in the lounge room and rocked it till he fell asleep at approximately 2am. Christine decided not to take him out of the pram as she did not want to disturb him as he at long last appeared to be sleeping peacefully at that stage. Christine did not use the harness in the pram to restrict Zac’s movements.
Christine then went to bed and slept until 7am when she awoke, believing Zac must have eventually slept well.

At 7am on 3 February Christine went to the lounge room and saw that Zac was on his tummy, with his head up against the top of the pram, with his cheek on the edge of the back of the pram and his head under the hood, which was not up. She picked him up and noticed he was cold to touch and his mouth was blue. She immediately called emergency services, who attended and pronounced Zac as deceased.

Dr Chris Lawrence, the Tasmanian Forensic Pathologist found that Zac weighed 9.5kg which was above the percentile for his age and was 75.5cm in length, above the percentile for his age. Congestion was present and blood tests confirmed Zac was suffering from a viral infection at the time. Blood tests also revealed the presence of paracetemol. Compression marks were observed on the left side of Zac’s head and neck consistent with the other evidence that Zac had been found with his head and neck trapped between the mattress and side wall of the pram wall.

The Pram/Stroller:

Christine purchased the pram on eBay in August 2006 for $60. She had contact with the vendor who informed her that it was in really good condition as she had only used to put her baby in and to walk the children to school. When the pram arrived there were no operating instructions or documentation with it. Christine placed a lamb’s wool on the top of the mattress and she took Zac for walks in the pram. He was able to sit up in it because it had adjustments for use as a stroller. A harness was supplied with the pram but Christine never used it as Zac was unable to sit up by himself but could sit in the stroller without being supported.

I have been unable to determine when the pram was manufactured, other than it was sometime prior to August 2006.
During the course of this lengthy investigation I sought a detailed and comprehensive report about the nature of and the suitability of the pram/stroller, including a reconstruction of events as best possible with the use of the subject pram. I accept the evidence of the very experienced investigators and adopt their comments and findings and evidence as follows:

  • This Emmaljunga brand of pram/stroller is made in Sweden. There was no Australian Standard sticker or label on the pram/stroller. On the brand-name plate was the following ‘S-280 22 VITTSJO SWEDEN’ which appeared to be the address of the manufacturer and/or possibly a reference to a safety standard operating in that country. The model name of the pram/stroller was not apparent on the item.
  • The pram can also be converted into a stroller for a baby/toddler to sit up. There was a torso harness fitted inside the pram and attached to the harness was a tag which stipulated that it should be used to secure a child at all times.
  • The pram has a sturdy steel frame with four wheels. The wheels are attached to the axles by plastic locking clips and accessible from the outside of the centre of the spoked-wheel rim.
  • There was a padded material support base together with a fabric patchwork liner attached to the frame.
  • There was a mattress base and a sheepskin liner together with a baby rug inside the pram.
  • On the frame (on one side) between the front and rear wheels was a clearly visible label. The writing on this label was in red. On the label was the following warning in uppercase printing, “DO NOT LEAVE CHILDREN UNATTENDED.” There were other warnings on this label.
  • The pram is collapsible however there is no evidence in this case that it was prone to sudden or unexpected collapse. A sliding lock on either side had to be actuated before it was able to collapse.
  • There is push down bar brake on the rear wheels.
  • The pram was manufactured with a fabric hood at the head end of the pram that can be lifted or lowered in a rotary type motion to cover or expose the head of the baby in the pram. The movement range of the hood was in the area of 120° to 130°. The handle of the pram can be alternated between the head or foot of the pram. At the time of this incident the handle was positioned at the head of the pram.
  • The pram (together with its contents) weighed 14.3 kg. The centre of mass was towards the front. A force of 8.5 kg was required to tip the pram towards the handle. It was found that considerable force had to be applied to the front of the pram in an endeavour to make it tip towards the front. It was found to be extremely stable at the front.
  • The pram was 340 mm wide from inside frame to inside frame. There was a distance of 150 mm from the top of the bedding to the top of the side frame. The top of the side frame was 750 mm above floor height.
  • The back rest of the pram was adjustable with three settings: horizontal, approximately 45° and vertical. The backrest was secured by a locking pin located under and behind the mattress base. The back rest was not prone to unexpected collapse.
  • The length of the capsule section of the pram (for a baby lying down) is 760 mm. This is measured from the foot to the hood when raised. Zac was found to be approximately 75.5 cm in length. Having regard to the detailed inspection of the pram it would appear that Zac was far too big to place in the pram when the mattress base was in the horizontal position.
  • The edge of the mattress base towards the hood is rounded with a diameter of approximately 10 mm.
  • The pram appeared capable of carrying out the function for which it was designed for. It clearly stated on the frame of the pram that children should not be left unattended in it.
  • When the hood is raised the material of the hood is stretched reasonably tightly against the mattress base. If the hood is down or in the semi-raised position the fabric is not tight against the mattress. The fabric can be pushed easily away from the edge of the mattress base creating a space of 170 mm between the mattress base and the taut fabric of the hood.

Some time prior to 1997 a five-month-old infant, Felix Penny died by being asphyxiated in an Emmaljunga pram. The New Zealand coroner found that baby Felix died as a result of a design fault in the pram namely that the hinged hood did not have secured fabric flaps to the body of the pram. There are some similarities in this case but circumstances were somewhat different. In any event, all such prams were recalled in 1997 and modifications made and the manufacturer provided safety pamphlets and warnings including, to use the harness provided and never leave a child unattended in a pram. At about the same time New Zealand promoted mandatory/standards for prams in both that country and Australia.

My investigations and research suggest that the Emmaljunga brand of prams and strollers is well regarded worldwide in providing safe and reliable prams and associated equipment and are regarded as being at the top of the range but with a cost to match.

The subject pram does not have a model number or name attached to it but on my research it is more likely than not to be a Jupiter or Coronette model. I have been unable to establish its year of manufacture or make any findings as to its probable year of manufacture, whether before or after the product recall in New Zealand in 1997 or before or after the 1993 and 2000 Aust & NZ voluntary safety standard. Research of manuals applicable to those prams obtained in 2007, 2011 and 2012, contain the following information –

Under the heading “Important Safety Information”

  • Always secure the child in the vehicle with the five-point harness. It is to be noted that in parts of the description of this pram that the harness comes with shoulder pads, suggesting the harness is more for use in the sitting position during transport.
  • Any “separate” harness must conform to BS 6684. This is likely a reference to a British standard.
  • Never use this vehicle as a bed for your child.
  • The pram body is intended for a child from 0+ to 8 months.
  • This vehicle is made for transportation only.
  • The depth of the top of the mattress to the top side of the body within 300 mm of the harness points should not be reduced to less than 140 mm. The likely inference to be drawn is that additional bedding might reduce this safety distance.
  • Under a heading “pram usage” it states - “cradle function. The pram body can be used as a cradle on the indoor, horizontal and even surfaces. Warning; never use the pram body as a permanent bed.”
  • The manual also has instructions for adjusting the five-point harness and those instructions relate only to a child seated and the diagram accompanying also depicts that. There is no similar instruction for using the harness in the pram or cradle position.

At the time of Zac’s death there existed an Australian and New Zealand Safety Standard in relation to prams – AS/NZ 2088:2000. This standard provided a benchmark for certain safety features relating to prams. However, compliance was voluntary.

A mandatory safety standard for prams and strollers (2088) came into effect in Australia from 1 July 2008. The standard requires the prams and strollers sold in Australia have a number of safety features including warning labels, model name and number and manufacturer details, tether straps and parking brakes. The Australian Competition and Consumer Commission (Product Safety Australia) published in September 2011 a safety alert warning as follows “entrapment causing suffocation - children have died after being caught in the structure of the pram or stroller when left there to sleep. Caution – never leave a sleeping child unsupervised in a pram or stroller.” And “never sleep children in prams as strangulation or suffocation can occur if a child moves about when asleep and becomes trapped in parts of the pram or stroller.”

It is certainly gratifying that there has been considerable action taken since at least 1997 which has resulted in improved safety standards.

Other Findings, Comments and Recommendations:

Zac’s death is a most tragic case and my fullest sympathies are extended to Rachael, Cameron, Christine and all other family and close friends touched by the tragedy and its aftermath. By the evidence before me following a lengthy and heart-rending investigation I am satisfied that there are no suspicious circumstances and that the death of Zac Cameron Rainbow was a tragic accident. I find that no person or persons contributed to Zac’s death.

I accept the conclusive opinion of Dr Lawrence and find that Zac died as a result of accidental positional asphyxia due to entrapment between the pram wall and the pram mattress.

What is most probable is that at some stage between 1am and 7am on Saturday the 3rd of February, Zac has pushed his blankets to the bottom of the pram and used them to push himself to the top of the pram and entrapped himself between the pram rear wall and mattress and died as a result of positional asphyxia. It is impossible to really know, but there is a probability that with Zac suffering from a viral infection and teething pain with consequent breathing and congestion difficulties, these factors may well have contributed in his death.

I find that the pram was in good general condition with no evidence of it folding or falling or collapsing or of its inherent design features being worn, broken or misapplied in practice. However, prams are not generally designed as sleeping places for babies/toddlers unless for very short times under very close carer control. What is quite clear from all of the evidence accumulated in retrospect is that Zac was too large for the physical dimensions of this pram as a sleeping place.
The investigation into Zac’s death has provided me with a large body of information about other instances of a similar nature and safety measures considered by other coroners in Australia and overseas. There are lessons to be learned from this tragedy and it is appropriate that I make comments and recommendations into ways of hopefully assisting in preventing further and similar deaths.

In March 2010, Kidssafe Victoria urged parents and carers not to leave children sleeping unattended in a pram or pram/bassinet, noting that between 1996 and 2006, 1448 infants suffered injuries from prams and strollers. It said that “leaving a child sleeping unattended in an unsuitable environment such as a pram can lead to severe injury or even death. It is dangerous to leave a child unattended in a pram or stroller, even when they are asleep, because they could wriggle and cause the pram or stroller to tip over. Children can also be strangled by the strap or suffocate if the pram collapses and therefore should not be left to sleep unsupervised.”

On the evidence before me it is likely that the pram used as Zac’s bed during this morning was an unsafe sleeping environment giving rise to the cause of death of positional asphyxiation.

Zac was not harnessed in the pram but I draw no adverse inferences in relation to that, other than given the length of time he was to be left unattended giving rise to the greater risk he might move within the pram into an unsafe position. However, on the available evidence there is nothing to suggest that he had the capacity to move out of the pram or tip it to his danger. There is insufficient evidence to conclude that had he been harnessed in the pram, this tragedy may have been averted. He was left alone in the lounge room some distance from his grandmothers’ bedroom, and he was thus unsupervised.

The importance of close supervision of a very young child when using nursery equipment designed for a specific and temporary purpose cannot be over emphasised. There seems to be a large amount of available product safety warning material in relation to the issues raised by this case, but I suspect the vast majority of the population are unaware of them or lack the ability or capacity to access the information, and they need to be brought to their attention on a regular basis.

Strong emphasis must be placed that occasional carers such as baby-sitters, grandparents and other relations and friends must be regularly informed about safety issues with new nursery equipment especially where they have little or dated experience whereby knowledge of issues and modern safety standards have rarely been considered by them. Generally, such persons should examine such equipment for key safety features and compliance prior to use or purchase.

Zac’s death highlights the importance of the vigilance required to be exercised by parents and carers in assessing the possible risks attendant upon children of Zac’s age who are becoming independently active, often in circumstances such as during the night when they are not being observed by their caregivers.

In situations where toddlers are left to sleep in a pram environment they must be continuously monitored and the pram must be rendered child-proof and safe.

Standards Australia compliance logos should be prominently and permanently placed on the item.

Importantly, in light of the circumstances surrounding Zac’s death, it is critical that parents/carers check the construction of relevant equipment and make sure everything fits snuggly without room for a baby to become wedged in any part of the mechanism of the equipment.

Equipment not complying with the current safety standard should be disposed of immediately and certainly should not be offered for sale.

Further, product designers, industrial designers and manufacturers must be all made aware of the variation of circumstances where death can occur and ensure that product designs are protective.

Accepting it may be a difficult task to achieve, I recommend consideration be given to introducing legislation designed to limit the on-sale of second hand nursery furniture only to accredited and licensed second hand dealers and precluding the import, whether via the agency of eBay or similar agencies, from overseas of such second hand equipment not complying with current Australian safety standards.

For the sake of completeness I would like to refer to an issue of concern to Zac’s parents, which is whether Christine, having consumed some alcohol during the evening of 2 February coupled with her taking her prescribed medication for depression and/or blood pressure, may have been relevant in this case? Unfortunately the initial police investigation did not include samples of breath or blood being taken from any relevant adults and when the possibility of that necessity was made, of course it was too late. Christine readily admitted that she consumed some alcohol during the evening she was caring for Zac. She had taken her prescribed medication the previous morning as was her usual practice and she had taken no medication for any pain associated with breaking her collarbone in November 2006.

Based upon her evidence, it being the only reliable evidence available, and the evidence of her general practitioner in relation to the prescribed medication taken by her and the timing of the ingestion of that alcohol and medication, I accept it would have had no bearing upon her ability to properly care for Zac. I can make no adverse findings against Christine or find any link that those substances may have caused or contributed to Zac’s death.

However, I recommend in future that police officers involved in the initial investigation involving the death of a child should, as a matter of course, seek consent to obtain a blood sample for analysis from any relevant person who was in close proximity to the deceased at the relevant time. I also recommend that any person charged with the care of a very young child should not be under the influence of any alcohol or drug to any extent whereby their capacities may be compromised.

I must also note that in this case the initial police investigation involving this very young child was not as comprehensive as it ideally could have been. A full scene reconstruction was not completed at the relevant time, nor was there a carefully recorded walk-through of the scene and the known circumstances surrounding the death. How Zac was positioned in the pram was not fully and properly addressed in the initial investigation. This lead to a much later reconstruction of events.

There was no video record of interview of relevant persons whereby an accurate account could have been recorded and retained with full and proper explanations of the scene and what was found for future analysis. The initial investigation left many unanswered questions which took an inordinate amount of time to attempt to answer by way of reconstruction or otherwise. I recommend there be further training for police officers who may be involved in the investigation of any paediatric death including a recommendation that all such investigations should be fully investigated by the Criminal Investigation Branch or an experienced senior investigator.

I accept that Tasmania Police has already taken steps to implement all of these recommendations.

Both of Zac’s parents and his grandmother were obviously significantly distressed immediately following his death and have remained so since. They had many unanswered questions for a significant period of time. I recommend that in all paediatric deaths there should be early and numerous family meetings to try and give immediate answers to the questions for the distressed family. To expedite that, the State Forensic Pathologist should be invited to attend such meetings so that clear explanations of causes might be provided and elaborated. There is no doubt in my mind that in this case, had the State Forensic Pathologist been invited to early meetings then many questions by Zac’s parents and others in relation to what did or did not occur or may have or may not have occurred, could have been answered to their early reasonable satisfaction.

The investigation into Zac’s death has taken an inordinate length of time for which I am most regretful, but it is hoped that the full and proper investigation and its comparison with like events around the world and the subsequent investigation into whether the particular pram should be recalled or not, and my recommendations might mean that Zac’s tragic death might not be in vain.

I wish to conclude by repeating my sincere condolences to the family of the Zac. I hope they may be able to move on in their respective lives with the fondest of loving memories of him.

DATED: Friday, 19 July 2013 at Hobart in the State of Tasmania

Glenn Hay