SUDI death of 42-day old female
Demographics
<1y, female
Date of death
2024-09-22
Finding date
2026-08-31
Cause of death
Sudden unexpected death in an infant (SUDI) in an unsafe sleeping environment
AI-generated summary
This is a SUDI death of a 42-day-old Aboriginal infant who died in an unsafe sleeping environment due to co-sleeping with her mother on a single mattress in an overcrowded unit. The mother, a 21-year-old with complex trauma, domestic violence exposure, and substance use, had been exited from supported accommodation (Ampe Akweke House) into homelessness one week before the infant's death. Multiple agencies—including health services, child protection, and youth accommodation services—failed to adequately address safe sleeping practices, housing insecurity, and maternal vulnerability. The coroner found limited evidence of documented safe sleep education throughout pregnancy and postnatal care, no safe sleeping device provided on exit from accommodation, and critical service coordination failures. The Department of Children and Families, despite knowing of the homelessness risk, did not provide interim accommodation or adequate protective support. The coroner determined this was a preventable death requiring enhanced safe sleep education systems, coordinated service delivery, and urgent homelessness prevention for vulnerable young mothers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Co-sleeping with mother on single mattress
- Maternal cannabis use
- Maternal cigarette smoking
- Soft bedding (doona/quilt)
- Overcrowded household (9 residents in 2-bedroom unit)
- Housing insecurity and homelessness
- Maternal fatigue and insufficient sleep
- Lack of documented safe sleep education
- No safe sleeping device provided on exit from supported accommodation
- History of transient tachypnea of newborn suggesting possible respiratory vulnerability
- Mattress positioned against wall with infant placed on side closest to wall (gap suffocation risk)
Coroner's recommendations
- NT Health review and amend Antenatal Care Pathways to include requirement to provide education on safe sleeping/safer co-sleeping and SIDS, with support of Aboriginal Health Workers using culturally appropriate materials
- NT Health develop a 'Safe Sleeping/Safer Co-sleeping/SUDI Screen' to be completed with all mothers attending antenatal/birth/postnatal services, clearly identifying risks and mitigation steps
- Department of Children and Families review and amend policies to ensure investigations/engagements with families are not closed prematurely when ongoing risks to child are identified; ensure active engagement between parent and service providers before closure
- Department of Children and Families, ASYASS, Ampe Akweke House, and Alukura Maternity Group Practice ensure comprehensive policies on infant safe sleeping/safer co-sleeping with culturally relevant materials and staff requirements to provide education, identify unsafe sleeping environments, and take proactive steps to mitigate risks
- ASYASS and Ampe Akweke House take all necessary steps to make available Pēpi-Pods, coolamons, or similar safe sleeping devices to mothers and babies identified as at-risk, with evaluation process for efficacy and delivery
- NT Government identify, quantify, and map homelessness of expectant and new mothers; identify, fund, and establish suitable accommodation with prioritized access noting infants under 3 months are most vulnerable; prioritize continuation of Aboriginal community-controlled service delivery
Full text
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