Heidrich, Bela

Contributing factors

• Maternal exhaustion and drowsiness after prolonged labour
• No information provided to mother about dangers of falling asleep while breastfeeding
• Inadequate supervision - gaps of 35-50 minutes without observation
• Mother fell asleep with baby at breast with nasal airway occluded
• Staffing distraction managing additional patient (Patient B) and communication system difficulties
• Lack of clear hospital policy on bed-sharing and breastfeeding lying down at time of incident
• Absence of documented risk assessment for maternal fatigue
• No buzzer offered or instructions given about contacting staff if tired
• Pillow placement may have restricted infant's ability to move away from airway occlusion

Coroner's recommendations

1. All Queensland Health facilities providing birthing services be provided with a summary of the three similar deaths in Queensland to ensure staff awareness of bed-sharing dangers
2. All Queensland Health birthing services facilities have a specific policy covering co-sleeping and bed-sharing that is easily understood and clearly matches supervision levels to patient needs
3. Queensland Health consider requiring: (a) risk assessment of maternal condition (lucidity and wakefulness) documented in medical records before lying-down breastfeeding; (b) mother provided information about dangers of falling asleep and given buzzer to contact staff; (c) determination of supervision level documented in medical records
4. Every prospective parent in Queensland be provided with specific oral and written information regarding SIDS/SUDI, bed-sharing, co-sleeping and risks during antenatal period, at hospital prior/during first feed and postnatal period prior to discharge
5. Further consideration given to framing various levels of supervision in breastfeeding policy to ensure consistent nursing approaches and training on new information
6. Queensland Health consider adopting Mater Mother's Hospital procedure for accurately recording bed-sharing, baby location and infant activity in medical notes
7. Queensland Health examine appropriateness of student midwives and endorsed midwives both working full caseloads with consideration for time allocation for supervision and training
8. Rockhampton Hospital ensure all RCA recommendations are implemented
9. Queensland Health ensure RCA process includes providing feedback to staff involved in incident investigation
10. Queensland Health ensure full record of staff attending MET calls is kept
11. Queensland Health ensure medical records accurately reflect date and time of assessment, distinguishing time of note entry from time of actual assessment; consider Dr Wakefield's recommendation that forms require recording of both times
12. Queensland Health ensure Patient Safety Officers in each Health Service District regularly assess and synchronise facility clocks