Demographics
0y, male
Coroner
McDougall
Date of death
2012-04
Finding date
2014-08-07
Cause of death
Sudden infant death syndrome (unclassified sudden infant death subclassification), possibly involving hypothermia
AI-generated summary
A four-month-old boy died in a caravan where he was placed in parental care following a Court Assessment Order. The cause was determined to be sudden infant death syndrome, possibly involving hypothermia given the cold environment (5-6°C), lack of heating, and the child found wet. Critical clinical lessons include: the risk assessment process that returned the child to parents with significant risk factors (chronic drug use, substance misuse denial, vulnerable infant, extensive family protection history) despite a 'very high risk' Family Risk Evaluation outcome; unsafe sleep environment in an unheated caravan during winter; and parental drug use on the day before death. The decision to return the child at the end of a Court Assessment Order, despite documented very high risk factors, represents a significant failure in child protection decision-making that warrants review of risk assessment and return-to-care procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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