Huber, Arisa

Contributing factors

• mother was exhausted after labour and birth with minimal sleep opportunity
• no specific warning given to mother about risks of bed-sharing for breastfeeding
• failure to conduct required 15-30 minute observation intervals while mother breastfeeding in bed
• 1 hour 45 minute period (5:00am to 6:45am) without any supervision of mother and baby in bed together
• nursing staff unaware of or had not read the hospital bed-sharing policy in place at the time
• inadequate staffing levels relative to patient numbers
• no explicit education provided to first-time mother about safe bed-sharing practices
• prolonged rupture of membranes (21 hours) and mother's fever creating additional risk context

Coroner's recommendations

1. Audit and review processes should be implemented to check that training on bed-sharing and co-sleeping policies is being effectively delivered and translated into appropriate action on wards
2. Staffing ratios should be reviewed with babies counted as individual patients rather than grouped with mothers as one patient, noting that acuity assessment is critical but overall patient numbers are important for education and safety
3. Education of parents and all medical and nursing staff must be enhanced, commencing in the community before birth and reinforced in hospital with physical demonstration
4. Resources must be provided and maintained in community sector to support and reinforce education provided in hospital, available both antenatally and postnatally in multiple languages and culturally inclusive formats
5. Specific warnings should be provided to mothers about risks of bed-sharing, particularly regarding excessive tiredness, sedation, or altered consciousness
6. A clear documentation system should be implemented (such as tick-box on chart or 'cot cards') to record time and physical location of baby on each observation, promoting safety and reminding staff of the issue
7. Policy documents should be hyperlinked so staff consider both risks and benefits of baby being in bed with mother
8. Training sessions for permanent night shift staff should be scheduled at the end of night shift to facilitate attendance, as previously done
9. Medical staff notification of policy updates should be enhanced to match nursing staff communication
10. Ongoing education and support services for families with infants should be continued in the community with accessible resources and guidance