Inquest into the deaths of Kayla EWIN and Iziah O’SULLIVAN

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

1. Ambulance Service NSW to amend policies instructing paramedics to take aural temperature of deceased infants under 12 months where clinically appropriate
2. 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
3. NSW Police Forensic Evidence and Crime Scene Services to use term 'coronial scene' rather than 'crime scene' for infant deaths determined to be accidental
4. NSW Police to revise Police Handbook to explicitly state officer in charge should minimise police presence at scene and hospital
5. NSW Police to review policies and training to ensure officers appropriately support families seeking time to say goodbye in SUDI context
6. NSW Police to consider amending P79A form and SOPs to include additional detailed SUDI questions regarding sleeping environment and circumstances
7. NSW Department of Forensic Medicine to review policies encouraging pathologists to routinely request and review crime scene photographs before signing off autopsy reports
8. Department of Forensic Medicine to review policies ensuring CNC role includes ensuring SUDI medical history form received and provided to pathologist timely
9. NSW Ministry of Health to review training policies regarding staff support for families seeking goodbye time in SUDI context
10. NSW Ministry of Health to implement proposed audit of revised SUDI medical history form over 12 months evaluating completion and timely provision to pathologists
11. NSW Ministry of Health to monitor duplication in taking medical history from families over 12 months to ascertain most sensitive approach
12. 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
13. 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