Coroner's Finding: SMITH Christopher John

Contributing factors

• inadequate carer supervision
• infant left unattended in bathtub while carer was on telephone
• loss of line-of-sight supervision
• infant's legs slipped into single leg hole of bath seat
• shallow depth of bath water (12.5-15cm) with minimal clearance under ring (1.5cm maximum)
• false confidence engendered by use of bath seat
• co-bathing with older sibling
• possible irritation from nappy rash encouraging infant to change position
• infant's limited coordination and understanding at 7 months old

Coroner's recommendations

1. The question of whether the sale of baby bath seats should be banned should be considered nationally by relevant regulatory agencies in light of these findings
2. A strong public awareness campaign should be instituted warning of the dangers of bathing infants in adult bathtubs and that infants should never be left unattended in a bathtub
3. Carers should always remain within arm's length when an infant is in a bathtub
4. Refinement of definition of adequate supervision in bathing of young children to within carer's arms reach
5. Development and distribution of fact sheets on recommended bathing practices for children five years and under
6. Identification of appropriate means of distributing information and raising awareness about infant bathing safety
7. Further Australian-based research into carers' perceptions of bath seats as a safety device versus bathing aid