Record of Investigation into deaths of four infants

Coroners Act 1995
Coroners Rules 2006


This finding is published simultaneously with three other findings in respect of tragic deaths of four infants in 2005 and 2006 in order to emphasise the significance of the issue in Tasmania and in the hope that consideration can be given to ways in which further similar deaths can be prevented. 

I have found the causes of death in these four cases to be as follows: 

  • Sudden Infant Death Syndrome
  • Sudden Infant Death Syndrome whilst bed sharing
  • Sudden Infant Death Syndrome whilst in an unsafe sleeping environment
  • Overlaying

In each case the infant died whilst in an unsafe sleeping environment. That fact sadly was not appreciated by the parents at the time. 

Sudden Infant Death Syndrome (SIDS) is defined as: 

"the sudden and unexpected death of an infant under one year of age, with the onset of the lethal episode apparently occurring during sleep, that remains unexplained after a thorough investigation including the performance of a complete autopsy and review of the circumstances of death and the clinical history" (1)

Before the cause of death is determined by autopsy, the sudden and unexpected death of an infant is often termed "sudden unexpected death in infancy" (SUDI). 

The death may be determined, after autopsy, to be as a result of a serious illness or a pre-existing medical condition, but most SUDI occur as a result of either SIDS or a fatal sleep accident (such as parental overlaying). 

Babies who die suddenly and unexpectedly as a result of an unforseen medical problem are not preventable; however scientists have identified similar risk factors that are present in SIDS, SUDI and fatal sleep accidents. 

The risk factors that have been identified are as follows:(2

Infant factors: 
  • low birth weight (less than 2500grams)
  • prematurity (less than 37 weeks gestation)
  • multiple births (twins, triplets)
  • first born
  • male gender
  • peak age between two and four months; infrequent in infants younger than 1 month and over 8 months of age
  • neonatal health problems including admission to special or intensive care baby unit
  • history of minor viral respiratory infections and/or gastrointestinal illness prior to death
  • Indigenous ethnicity
Parental factors: 
  • young mothers (less than 20 years)
  • unmarried or without supportive partners
  • high maternal parity (number of births by mother)
  • short inter-pregnancy intervals (less than six months between pregnancies)
  • non-attendance or poor/delayed prenatal care
  • cigarette smoking during pregnancy and after birth
  • alcohol and drug abuse
  • Indigenous ethnicity
Environmental factors: 
  • low socio-economic status (socially disadvantaged by occupational status, lower education level, unemployment)
  • sleeping on soft surfaces and loose bedding
  • prone (on stomach) and side sleeping position
  • winter months
  • over wrapping/overheating
  • sleeping environment (i.e. shared sleeping on couch/chair, infant alone in adult bed; some circumstances of shared sleeping)

By removing known risk factors and providing a safe sleeping environment most of these deaths are preventable. 

The National SIDS Council of Australia, trading as "SIDS and Kids", was founded in 1987. Through its health promotion program, SIDS and Kids Safe Sleeping, it has been instrumental in reducing the infant mortality rate by around 84%. The organisation has had major success in bringing the issue of infant death into the public forum and attracting funding for research into the causes of sudden infant death and methods of prevention. 

The organisation is largely self-funded through the Red Nose Day Campaign and associated activities. Red Nose Day is the cornerstone of SIDS and Kids fundraising Australia wide. It is widely acknowledged as the first "signature" fundraising day of its kind in Australia. Since 1988 it has raised money for education and research into sudden and unexpected infant death, a wide range of family support programs, and community education. 

SIDS and Kids comprises a National Office based in Melbourne and nine member organisations located around Australia. 

The Tasmanian office is located at Room 20, 2 Spring Street, Burnie. It is funded by SIDS and Kids Tasmania for one full time staff member (the Executive Officer) and a part time staff member. Mrs. Sharon Davis, the Executive Officer is responsible for overseeing day-to-day operations. These include the running of Red Nose Day and other fundraising initiatives, community education, support services, monitor program, research library and the general administration associated with running a not for profit organisation. Whilst Mrs Davis tries to ensure a spread of time in all areas of the State, most of her "face to face" contact work is done in the North and North West regions. 

In its Safe Sleeping campaign, SIDS and Kids has widely publicised measures that should be adopted to reduce or eliminate the risk factors referred to above. 

The main risk reduction messages circulated by SIDS and Kids are as follows: 

  1. Put baby on his/her back to sleep from birth. Do not sleep baby on its tummy or its side.
  2. Parents should not smoke before or after the birth of the baby.
  3. Sleep baby with face uncovered. There are two ways to achieve this. Place baby’s feet to the foot of the cot, use only lightweight blankets, and tuck them in securely. Alternatively, a sleeping bag can be used without bedding. A safe infant sleeping bag is made in such a way that a baby cannot slip inside the bag and become completely covered. The sleeping bag should be the correct size for the baby with a fitted neck, armholes but no hood. Do not put a hat on baby to sleep.
  4. Have a safe cot, safe mattress, safe bedding and safe sleeping environment for baby day and night. In this regard it is recommended that the cot should meet Australian Standards. Keep quilts, doonas, duvets, pillows and cot bumpers and fluffy toys out of the cot. Babies should not be left to sleep on tri-pillows or U shaped pillows due to the risk of suffocation. Prevent the baby overheating by ensuring that his/her head and face is always uncovered and by avoiding over heated rooms. Always dress baby appropriately for the room temperature.
  5. Do not sleep with the baby on any sleep surface (bed or sofa). There appears to be no increased risk of SIDS or fatal sleep accidents whilst sharing a sleep surface with baby whilst feeding, cuddling and playing, providing baby is returned to his/her own sleeping environment before the parent goes to sleep. As indicated, the risks of sharing a sleep surface include overlaying of the baby by another person, entrapment or wedging and suffocation from pillows and blankets.
  6. It is preferable to sleep baby in its own cot next to the parent’s bed for the first six to twelve months of life as this has been shown to be protective.

The above messages have been circulated prominently to the public since the early 1990’s when the SIDS and Kids Safe Sleeping campaign began. In reducing the rate of deaths, SIDS and Kids estimates that the lives of over 4500 infants have been saved. 

The circumstances of the four deaths that are the subject of this investigation have been reviewed by the Paediatric Mortality and Morbidity Sub-Committee ("the Committee") of the Council of Obstetric and Paediatric Mortality and Morbidity ("the Council"). The Council is established under the Perinatal Registry Act 1994 (Tas), an Act administered by the Minister for Health. 

The functions of the Council (and the Committee) as set out in the Act are, amongst other things, to investigate the circumstances surrounding, and the conditions that may have caused, (a) maternal and perinatal deaths, and (b) deaths of children in Tasmania in the age group from 29 days to 14 years. 

The Committee reviewing these deaths comprised: 

Dr Elizabeth Hallam, Paediatrician;
Dr Chris Lawrence, State Forensic Pathologist;
Dr Simon Parsons, RACP Representative and Neonatologist (and current Chair of the Council and the Committee);
Mr David Fanning, Commissioner for Children Tasmania; and
Dr Geoff Shannon, GP Representative. 

In its reports to the Coroner the Committee commented as follows: 

"The number of infant deaths which may be attributed to unsafe sleeping environments is of ongoing concern to the Committee and consideration should be given to assessment, education, monitoring and follow-up where a child is identified as high risk or is of low birth weight. Current information in relation to safe sleeping does not appear to be getting through and additional support in the community is warranted." (23 January 2006 and 27 March 2006)

"The committee continues to highlight, however, their concern that education regarding bed sharing and its risks needs to be widely disseminated to the general public." (23 October 2006) 

Before the introduction of the SIDS and Kids Safe Sleeping program it was recognised that Tasmania had twice the national average of SIDS deaths. This rate has been reduced dramatically by that program and the hard work of SIDS and Kids Tasmania in disseminating the safe sleeping message to the community and health professionals in this State. SIDS and Kids Tasmania acknowledge that there is still a great deal to be done in this area, much of which is dependant upon receipt of sufficient funding. 

Upon analysis of the rate of recent infant deaths in Tasmania, it seems that the comments of the Committee are well justified. 

I have compared data obtained from the National Coroners Information System3 for SIDS and unexplained infant deaths in each State between July 2000 and May 2007 with State populations. Based upon this information Tasmania has the second highest rate of SIDS and potentially preventable infant deaths after the Northern Territory. 

Tasmanian Coronial records for infant deaths recorded as caused by SIDS, overlaying, asphyxia or "undetermined" indicate that 31 Tasmanian infants under the age of 12 months have died between May 1999 and July 2006. 

A further three infants died with the cause of death being given as bronchopneumonia in circumstances of bed sharing or an unsafe sleeping environment. 

In 33 out of these 34 infant deaths the circumstances involved an unsafe sleeping environment. Predominantly the infants died whilst co-sleeping with one or both parents in an adult bed and in adult bedding. Two deaths occurred whilst the mother was sleeping on a couch with the infant. Nine deaths occurred after the infant had been put to sleep in its own cot but on its stomach or side. Three deaths occurred after the infant had been put to sleep in its own cot but amongst adult bedding such as doonas and quilts or loose bedding that covered the infant’s face. Additional risk factors present in many of these deaths were the infant being in an apparently overheated environment, parental smoking and consumption of alcohol or drugs. 

It appears that almost all of these deaths were potentially preventable with modification or removal of the risk factors present. 

Infants under the age of one year remain the most vulnerable group of children to date. Whilst much has been done to reduce the number of sudden unexpected deaths and SIDS deaths in Tasmania they still make up a high proportion of potentially preventable deaths of children under 18 years of age. By way of comparison, National Coroners Information System statistics indicate that since July 2000, 45 children in total died in Tasmania as a result of vehicle and aeroplane crashes. 

To address the problem the governments of some Australian States, (New South Wales, Queensland and the ACT), have funded and conducted specific reviews concerning sudden unexpected deaths in infancy. 

In 2005, for example, the NSW Child Death Review Team published its report entitled "Sudden Unexpected Deaths in Infancy: the New South Wales Experience". The aims of that review, amongst other things were "to consolidate existing knowledge of unsafe sleeping environments; determine current parental practices in New South Wales in relation to risk factors that contribute to sudden unexpected deaths; describe current policy and practice in NSW when responding to these deaths…" 

Some of the recommendations from that review were as follows: 

  • That the NSW Government and SIDS and Kids NSW should place more emphasis on the risk associated with the side sleeping position in prevention strategies;
  • Prevention strategies in relation to safe sleeping and smoking should particularly target parents with lower levels of education and families who are socio-economically disadvantaged. This recommendation was based upon the finding that those groups have higher rates of risk factors for SIDS;
  • That the NSW Government should adopt a multi-agency integrated system of response to sudden and unexpected deaths in infancy.

The Queensland Commission for Children and Young People and Child Guardian was established in Queensland in 2003. Its inaugural report in September 2005, which analysed child and youth deaths registered in Queensland for a period of 18 months (January 2004 - June 2005), made three specific recommendations to Queensland Heath relating to sudden unexpected deaths in infancy: 

  • Develop and implement a statewide policy about safe sleeping practices
  • Develop a training package in relation to the policy
  • Develop culturally appropriate materials and communication strategies to convey safe sleeping messages to all parents, especially those of high risk

Both NSW Health and QLD Health now have health policies in place which include Safe Sleeping policies. SIDS and Kids Australia has indicated the desirability of implementation of Safe Sleeping Health Policies in all States. 

No similar review has as yet been conducted in Tasmania, nor does the Tasmanian government fund a specific SIDS program through the Health Department.

I have been advised that three State-based SIDS and Kids organisations (Australian Capital Territory, Western Australia & New South Wales) currently receive funds for a specific SIDS program through the health departments of those respective States. Queensland, Northern Territory and South Australia are currently applying to receive funding. The Australian Capital Territory, closest to the Tasmanian population, receives funding of $120,000 per annum of which approximately $40,000 is for delivery of the safe sleeping program. 

It appears that in this State the higher rate of SIDS is attributable to an increased presence or number of one or more of the risk factors referred to on page 2. 

For example in relation to maternal smoking in pregnancy statistics were released in October 2007 by the Tasmanian Department of Health and Human Services. In 2005, 27.6% of Tasmanian women smoked whilst pregnant, the second highest rate after the Northern Territory. For public hospital maternity patients the rate of smoking during pregnancy was 38.2%. It is to be noted that smoking during pregnancy gives rise to a higher risk of a low birth weight baby, and in turn a higher risk of SIDS. I would also assume, although not dealt with in the study that a significant proportion of these smokers, or their partners, continue to smoke after the birth of the child. This too represents a risk factor as discussed. 

I also note that the younger average age of Tasmanian mothers as compared to most other States and possibly corresponding lower levels of literacy/education may explain lack of awareness and non-implementation of correct safe sleeping practices. 

However, these comments are preliminary observations only and I do not purport to analyse in this document all of the reasons for the significance of the problem in Tasmania. 

Role of Health Professionals 

Health professionals are an important source of information as they are ideally placed to educate new parents and promote and influence infant sleeping practices adopted by parents.(4,5,6,7) Health professionals must model safe sleeping practices while the baby is in hospital and provide consitent information once the baby is home. (5,6,7) Several reports cite instances of inappropriate professional practice that may have perpetuated incorrect sleeping postion used by parents. (4,5,6,8) A report of sudden unexpected death in infancy conducted in the United Kingdom concluded that health care professionals contributed to 32% of SIDS deaths thruogh poor identification of key SIDS risk factors, poor communication and poor support of vulnerable families.

As stated, the Department of Health NSW publishes Policy Directives to relevant government hospitals and facilities, compliance with which is mandatory. One mandatory policy directive by that Department to government maternity facilities includes a requirement that staff, in addition to the usual safe sleeping messages and practice, conduct a risk assessment to ensure the infant’s safety whilst bed sharing in the maternity unit. 

I have in the course of this investigation received comprehensive and helpful information from the major public and private maternity hospitals in Tasmania and the Family Child and Youth Health Service. These bodies are clearly committed to imparting safe sleeping practices and reducing the rate of SIDS deaths. 

All hospitals have developed their own guidelines and policies with regard to safe sleeping practices and are aware of the need to provide regular education to staff. The hospitals also indicate awareness of the need to update policies when appropriate and in line with current research in the area. The Launceston General Hospital is currently updating its policies to reflect those in some other States; in particular the hospital is developing a risk assessment concerning bed sharing in line with NSW and Queensland strategies. At the Royal Hobart Hospital staff members are required to complete an Incident Report form if a parent is noted to be bed sharing with the infant. Currently the Royal Hobart Hospital is reviewing a draft policy for safe sleeping practices and the steps to take if a parent does not follow those practices. 

The policy of the Hobart Private Hospital is that parents do not sleep with their baby in hospital nor later when they take the baby home. 

All hospitals indicate the requirement that staff reinforce to parents the correct and consistent safe sleeping message to new parents through demonstration and discussions. The hospitals require documentation of discussions between staff and parents in this regard. The hospitals also provide written safe sleeping information, such as the SIDS and Kids brochures that clearly and simply describe for parents safe sleeping practices. Additionally, every new parent is given a Personal Child Health Record Book containing a section on safe sleeping practices. Parents are also shown safe sleeping videos in either antenatal classes or in hospital. In at least two hospitals safe sleeping instructions are attached to the infant’s cot. 

Most hospitals still identify the following needs in the implementation of safe sleeping policies: 

  • Adequate funding to ensure that staff are educated regularly, informed of new developments and research in this area, and are fully trained and equipped to provide correct and consistent information parents;
  • Further educational materials and resources for staff and parents.

SIDS and Kids information indicates that in New South Wales and Queensland 30-33% of midwives incorrectly placed babies on their sides to sleep. The reviews in those States therefore identified a need for further education of staff. 

This issue of incorrect practices by Tasmanian nurses and health professionals has not specifically been studied. It might be surprising perhaps, if the results were significantly different. However given the role of those persons in terms of influencing parental behaviour and the stated need for their ongoing professional education, the issue should be given consideration in any coordinated strategy that is implemented surrounding further training and education. 

Antenatal Education 

Whilst in hospital new parents need to recover from the birth, and undertake multiple activities and tasks around parenting. They are provided with a large amount of information on a variety of subjects in a relatively short time. In the case of parents who are young, have substance abuse issues or are not well educated (maybe with literacy problems), it is not difficult to understand that much information and advice they receive might not be absorbed. Therefore despite demonstration and repetition of correct safe sleeping practices by hospital staff there is a need to ensure that the same information is correctly and consistently repeated both antenatally and after discharge from hospital.

All hospitals offer antenatal classes for parents. Although antenatal classes deal with safe sleeping practices, information from at least one public hospital, the Launceston General Hospital, suggests that only 40% of parents attend classes and those attending are probably not those at the greatest risk despite the classes being offered free of cost.

Mrs Davis, of SIDS and Kids Tasmania, suggests that it is important that safe sleeping practices are taught at an early stage, particularly in light of the high proportion of young parents in Tasmania. She therefore suggests education of school children at Grade 10 level would be beneficial and would capture a wide group of potential parents. She suggests that such an initiative could be combined with an anti-smoking message emphasising risks to an infant of smoking in pregnancy and after birth. 

After Discharge from Hospital 

After discharge from hospital the Family and Child Health Nurse (FCHN), employed by the Department of Health and Human Services routinely discusses safe sleeping and bed sharing. This discussion occurs at the initial assessment visit at 1-2 weeks post discharge and is required to be documented in the infant’s Personal Health Record. The FCHN is also required to discuss safe sleeping practices at the infant’s 6 week visit and document that discussion. I am informed that almost all new mothers and babies are seen by the FCHN through the first 6 week period after discharge from hospital. This period is a crucial time for establishment of correct parenting practices. Thus the role of the FCHN is critical. Area/service Development Coordinator for the Family Child and Youth Health Service, Jean Shaw, indicates a need for reinforcing orientation programs for new staff and ongoing professional development programs for all staff. Mrs Davis also indicates a particular need to ensure that each FCHN is imparting correct information and applying standard guidelines. 

The importance of disseminating correct information has been highlighted by Byard, Cains Noblet and Weber in a recent article discussing the use of tri pillows and bed sharing. They state: 

"It appears, despite clear evidence that certain sleeping situations are potentially dangerous for infants, as well as the widespread dissemination of this information in safe-sleeping literature, that certain organisations or individuals continue to give a contrary message. What hope do parents have of understanding these issues and making informed decisions to optimise the safety of their infant’s sleeping environment if they are exposed to such conflicting messages and advice?" 

Mrs Davis advises of the need in Tasmania for at least one government funded SIDS educator. That person would have a role in not only educating hospital staff and FCHNs but potentially in schools. She indicates that such an educator might have a role in liaising with other relevant bodies that influence parental behaviour during the early post natal period. These include obstetricians, general practitioners, paediatricians, parenting and childcare centres, family day carers and the Australian Breastfeeding Association. 

Mrs Davis states that SIDS and Kids are not financially able to fund such a position. She states that Red Nose Day is now competing with many other fundraising days. I am advised that over recent years the funding of SIDS and Kids from the Red Nose Day has decreased as other signature charity days rise in prominence. I am advised, for example, that SIDS and Kids is now not in the top 200 Charities supported in Australia. 

With regards to the effectiveness of dedicated SIDS workers, I note the possible correlation that the highest proportion of SIDS and preventable infant deaths occur in the Southern region of the State, being the area furthest away from where Mrs Davis predominantly works. 


From the material obtained in this investigation I comment as follows: 

  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.

The deaths of the four infants concerning the subject of these findings were all associated with an unsafe sleeping environment. Two of the deaths involved bed sharing. Parents and infants derive comfort and enjoyment by sharing a bed for feeding or cuddling. However, in line with the SIDS and Kids recommendations, I would urge parents of infants to return the infant to his/her own cot before the parent goes to sleep, and to place the infant on its back for sleeping. The heartbreak of losing an infant life in such circumstances has far reaching consequences for the family and for the community as a whole. 


1. I recommend government and key stakeholder organisations give consideration to the issues and comments in this finding and give consideration to the development and implementation of strategies for the prevention of sudden infant deaths in Tasmania.

2. Specifically, I recommend that the Department of Health & Human Services adopt a lead role in: 

a. developing a single set of consistent guidelines that define the appropriate strategies to be implemented by parents, carers, and health professionals for the reduction of risk factors in sudden unexpected deaths of infants; 

b. considering whether the Paediatric Mortality and Morbidity Sub-Committee of the Council of Obstetric and Paediatric Mortality and Morbidity should be responsible for drafting or advising on the guidelines, with continuing responsibility for drafting or advising on updates to the guidelines in accordance with current medical research; 

c. publishing the guidelines amongst the medical and nursing professions in both the public and private sector; 

d. publishing the guidelines in the wider community generally, including amongst current and future parents (eg. in antenatal classes and secondary schools); 

e. conducting a SIDS education program statewide (perhaps by employing a SIDS educator), with particular reference to any high risk sub-groups; 

f. implementing a requirement that all child health nurses/community nurses receive updated training about the guidelines, and 

g. ensuring that SIDS risk assessments are conducted with parents upon the mother’s discharge from hospital, with appropriate information about the guidelines provided to them. 

Before I conclude this matter, I wish to convey my sincere condolences to the families of the deceased.

Dated: 20 May 2008 at Hobart in the state of Tasmania.

Olivia McTaggart

A copy of this finding was sent to :

Minister for Health
State and Chief Coroners
Secretary, Department of Health and Human Services
SIDS and Kids Australia (National and Tasmanian Branch)
Commissioner for Children
Chief Executive Officer, Kidsafe
Australian Nursing Federation, (National and Tasmanian Branch)
Australian College of Midwifes
Royal Australian Colleague of General Practitioners
Australian Medical Association
General Practice Tasmania
Manager, National Coronial Information System
Manager, Council of Obstetric & Paediatric Mortality & Morbidity, Tasmania
Australian Dept of Health and Ageing (Minister for Health and Ageing (The Hon Nicola Roxon MP)


1. Krous HF, Beckwith JB, Byard RW, Rognum TO, Bajanowski T, Corey T, Cutz E, Hanzlick R, Keens T, Mitchell E,. "Sudden infant death syndrome (SIDS) and unclassified sudden infant deaths (USID): a definitional and diagnostic approach". Pediatrics 2004;114:234-8

2. Moon RY, Horne RS, Hauck FR. "Sudden infant death syndrome". Lancet 2007;370:1578-87; Byard RW, Krous HF. "Sudden infant death syndrome – overview and update". Pediatr Develop Pathol 2003;6:112-27

3. The National Coroners Information System (NCIS) is a national internet based data storage and retrieval system for Australian coronial cases.  Information about every death reported to an Australian coroner since July 2000 (January 2001 for Queensland) is stored within the system, providing a valuable hazard identification and death prevention tool for coroners and research agencies.

4. Fleming PJ, Blair PS, Bacon C, Berry J (Eds) (2000) Sudden unexpected deaths in infancy: the CESDI SUDI studies 1993-1996. London: The Stationery Office

5. Roberts H, Upton D (2000) New mother’s knowledge of Sudden Infant Death Syndrome, British Journal of Midwifery 8(3): 147-50

6. Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ (2000) Factors associated with caregivers’ choice of infant sleep position, 1994-1998: The National Infant Sleep Position Study. JAMA: Journal of the American Medical Association 283(16): 2135-2142

7. Young J, O’Rourke P (2003) Improving attitudes and practice relating to Sudden Infant Death Syndrome and the Reduce the Risk messages: The effectiveness of an educational intervention in a group of nurses and midwives.  Neonatal, Paediatric and Child Health Nursing 6(2): 4-14

8. New South Wales Child Death Review Team (2005) Sudden Unexpected Deaths in Infancy: The New South Wales Experience.  Report written for the NSW Child Death Review Team by the Commission for Children and Young People (Malins P, Burke S,