Inquest into the deaths of Kayla EWIN and Iziah O’SULLIVAN
Deceased
Kayla Ewin and Iziah O'Sullivan
Demographics
unknown
Date of death
2012-12-23
Finding date
2019-11-29
Cause of death
Kayla Ewin: Unascertained (SUDI 0+); Iziah O'Sullivan: Unascertained (SUDI 0)
AI-generated summary
Two infants died suddenly and unexpectedly at home with unascertained causes classified as SUDI (Sudden Unexpected Death in Infancy). Key clinical lessons include: improved documentation of scene temperature (relevant for hyperthermia assessment), completion of SUDI medical history forms by hospital staff (consistently missing, complicating autopsy interpretation), timely provision of scene photographs to forensic pathologists, and coordination between agencies. Family support was inadequate—parents felt under suspicion, lacked time with deceased infants, and experienced unnecessary police presence during grieving. System failures included incomplete medical histories (less than 50% provided to forensic pathologists), lack of standardised training for staff supporting bereaved families, and absence of early interagency clinical review meetings. Recommendations focus on standardising SUDI investigation procedures, improving family care protocols, ensuring complete medical documentation reaches pathologists promptly, and establishing centralised paediatric expertise available 24/7.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- inadequate SUDI medical history documentation at hospital
- failure to provide SUDI medical history form to forensic pathologist
- lack of scene temperature documentation
- incomplete crime scene photography provision to pathologist
- inadequate family support and communication during investigation
- excessive police presence at hospital during grief
- inconsistent terminology causing family distress (crime scene vs coronial scene)
- lack of standardised training for staff supporting bereaved families
- no early interagency clinical review meeting protocol
- missing opportunities to obtain objective environmental data at scene
Coroner's recommendations
- Ambulance Service NSW to amend policies instructing paramedics to take aural temperature of deceased infants under 12 months where clinically appropriate
- NSW Police to revise Police Handbook SUDI section to instruct officers to assess whether term 'coronial scene' is preferable to 'crime scene' and consider impact on family
- NSW Police Forensic Evidence and Crime Scene Services to use term 'coronial scene' rather than 'crime scene' for infant deaths determined to be accidental
- NSW Police to revise Police Handbook to explicitly state officer in charge should minimise police presence at scene and hospital
- NSW Police to review policies and training to ensure officers appropriately support families seeking time to say goodbye in SUDI context
- NSW Police to consider amending P79A form and SOPs to include additional detailed SUDI questions regarding sleeping environment and circumstances
- NSW Department of Forensic Medicine to review policies encouraging pathologists to routinely request and review crime scene photographs before signing off autopsy reports
- Department of Forensic Medicine to review policies ensuring CNC role includes ensuring SUDI medical history form received and provided to pathologist timely
- NSW Ministry of Health to review training policies regarding staff support for families seeking goodbye time in SUDI context
- NSW Ministry of Health to implement proposed audit of revised SUDI medical history form over 12 months evaluating completion and timely provision to pathologists
- NSW Ministry of Health to monitor duplication in taking medical history from families over 12 months to ascertain most sensitive approach
- NSW Ministry of Health and Police to implement interagency early clinical review meeting within 1 week (or as soon as practicable, no later than 1 month) after SUDI death, evaluating implementation within 12 months
- NSW State Government to consider creating paediatric CNC role at Coronial Case Management Unit trained in SUDI investigations, available 24 hours daily, extended to all accidental child coronial deaths
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