Inquest into the death of Baby S, Baby K, Baby B - (Co Sleeping)

Contributing factors

• co-sleeping with parents on soft mattress
• heavy blankets and bedding
• parental intoxication (alcohol and cannabis)
• parental smoking
• infant prematurity and small size
• multiple co-sleepers
• lack of safe sleeping education
• lack of culturally appropriate health information
• lack of Aboriginal health worker support
• lack of safe sleeping devices (Pēpi-Pods/Coolamons)
• housing instability and overcrowding
• transience and homelessness
• domestic violence and family violence
• lack of interpreters during antenatal care
• inadequate child protection case follow-up
• upper respiratory tract infection (Baby K)

Coroner's recommendations

1. DCF to review and amend policies to prevent premature closure of Strengthening Families cases; cases should not close until evidence of service engagement and network meetings are documented
2. NT Government to identify and quantify need for alcohol rehabilitation services in Central Australia that can accommodate pregnant and new mothers with infants, and progress service provision with appropriate funding
3. NT Health and DCF to develop accurate, culturally sensitive and appropriate educational materials about infant safe sleeping in Aboriginal languages through authentic co-design with Aboriginal stakeholders; materials should include realistic representations of risks, complementary tools such as videos in language, and awareness campaigns targeting Aboriginal communities and grandmothers
4. NT Health, DCF and Central Australian Aboriginal Congress to ensure clear, updated policies on safe sleeping practices with culturally appropriate materials; staff must provide ongoing education, identify unsafe sleeping environments, and provide practical assistance including safe sleeping devices
5. NT Health to amend Safe Sleeping Guideline within 12 months to permit in-hospital co-sleeping only with side cots or larger beds with safe sleeping devices and culturally appropriate education; practices such as wedging cot mattresses between bed frame and mattress must cease
6. NT Health, DCF and Central Australian Aboriginal Congress to form working group to promote availability of Pēpi-Pods, Coolamons or similar devices, evaluate efficacy of safe sleeping devices and education materials, and share information
7. NT Health to review and increase use of Aboriginal Health Workers, Aboriginal Liaison Officers and interpreters in antenatal, intrapartum and postnatal care; consider implementing bi-cultural pairing approach as practised by Central Australian Aboriginal Congress
8. NT Health to improve health information-sharing by ensuring use of Individual Health Identifiers (IHI) for all mothers and babies in antenatal, intrapartum and postnatal care
9. NT Government to re-establish comprehensive Child Death Review Process with necessary expertise and resources; process should consider uniform classification for SUDI, SIDS and unsafe sleeping environment deaths
10. NT Health forensic pathologists to establish process for explaining SUDI/SIDS/unsafe sleeping infant deaths to parents or caregivers in culturally respectful manner, in consultation with Northern Territory Police, Coroner's Grief Counsellor and Aboriginal community representatives