Inquest into the death of Jack LOH

Contributing factors

• Inappropriate and unsafe bassinet too small for child's age and size
• Child placed in prone position in confined bassinet
• Extraneous bedding material (pillow, wrap, sheet) in bassinet
• Child placed while fully clothed with dribble bib
• Poor ventilation in sleeping room (windows and door closed, no fan or air conditioning)
• Elevated room temperature on day of death
• Inadequate supervision—not checked every 10-15 minutes as required, 35-45 minutes elapsed without checking
• Educator's CPR accreditation lapsed
• Failure to move to cot despite child's age and ability to roll
• Use of bassinet instead of available portable cot
• Two-year-old child sleeping in same room
• Failure of family day care provider to adequately supervise and train educator
• Failure of family day care provider to properly inspect sleeping environment
• Failure to communicate to parents use of bassinet
• Regulatory authority's delayed follow-up and failure to reassess service after identified non-compliance

Coroner's recommendations

1. Amend the National Law so that family day care Educators are required to undertake mandatory safe sleep training
2. Support proposal under National Quality Framework review to require that family day care Educators complete Certificate III in Early Childhood Education and Care before commencing as an Educator
3. Amend the regulatory regime in relation to family day care Services so that Approved Providers are required to undertake a risk assessment in respect of an Educator's implementation of sleep and rest policies and procedures
4. Amend the National Law and/or National Regulations to expressly prohibit the use of bassinets in all early childhood education and care settings
5. Amend the National Law and/or National Regulations to require that an applicant for Provider approval (or the persons with management and control of an applicant) must: (a) have an approved diploma level education and care qualification or an approved early childhood teaching qualification; (b) have at least three years' experience in an education and care Service or children's Service or a school or in a Service regulated under a former education and care services law; and (c) undertake a risk-based knowledge assessment administered by the Department to demonstrate an applicant has a sufficient standard of knowledge of how an education and care Service is to operate in compliance with the National Quality Framework
6. Continue to work with the Commonwealth Government and other jurisdictions through the National Quality Framework review to enable a contemporaneous family day care register to capture: (a) names and dates of birth of children attending the Service; (b) names and contact phone numbers of educators, coordinators and educator assistants; (c) days and hours of care and number of children attending per session; (d) relevant dates (for example, residence assessment date, educator commencement/end dates); (e) educators operating above ratio (and the applicable approved provider approved exceptional circumstance); and (f) Provider Digital Access numbers for family day care Educators and Coordinators
7. Develop and implement an information sharing protocol between NSW Department of Education and Department of Education, Skills and Employment (DESE) which may require legislative amendment, such that it provides the NSW Regulatory Authority with access to relevant information held by DESE with respect to Approved Providers and family day care Educators