Coronial
QLDhome

B, an eleven week old infant - Non-inquest findings

Deceased

B

Demographics

0y, female

Coroner

Bentley

Date of death

2016-04-02

Finding date

2021-02-17

Cause of death

Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying

AI-generated summary

An 11-week-old infant died while co-sleeping with her mother in a bed shared with siblings. The mother had smoked cannabis before sleep and was found overlaying the infant at 3:30am; the baby was discovered head-down beside the bed at 6:30am. Autopsy could not conclusively determine cause of death but indicated probable SIDS or asphyxiation from co-sleeping/overlay. Clinical lessons include: recognising SIDS risk factors (co-sleeping, parental substance use); adequate child protection assessment addressing totality of risks; collaborative practice between child protection and health services; and counselling families on safe sleep practices. The case highlights failures to sufficiently weight co-sleeping and substance abuse risks in safety planning.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricspathologyemergency medicine

Error types

systemcommunication

Drugs involved

cannabisamphetaminebenzodiazepinestobacco

Clinical conditions

sudden infant death syndromeasphyxiationpositional asphyxiaparental substance abuse disordermaternal borderline personality disordermaternal anxietypaternal adjustment disorder

Contributing factors

  • Co-sleeping in bed with mother and siblings
  • Parental cannabis use prior to sleep
  • Parental substance abuse (amphetamines, benzodiazepines, cannabis)
  • Parental mental health issues
  • Inadequate child protection safety planning
  • Insufficient attention to co-sleeping and substance abuse risks in safety assessment
  • Lack of collaborative practice between child protection and health services
  • Infant tested positive for drugs at birth (amphetamines, benzodiazepines, cannabis)

Coroner's recommendations

  1. Highlight risk factors for SIDS including co-sleeping and parental drug use
  2. Improve collaborative case planning and collaborative practice between the Department and Queensland Health
  3. Adequately address and consider co-sleeping and substance abuse impacts in child protection assessments
  4. Ensure safety plans sufficiently mitigate identified risks through comprehensive consideration of totality of family issues
  5. Implement improved SCAN procedures for multidisciplinary team case management (changes noted as already made post-death)
Full text
Official source Archived copy

Related cases from QLD

QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…

paediatricsemergency medicinediagnosticdelaymethamphetamine

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.