Coroner's Finding: Pearce, Jasmine Rose
Deceased
Jasmine Rose Pearce
Demographics
<1y, female
Date of death
2013-01-27
Finding date
2015-05-27
Cause of death
suffocation under bedding
AI-generated summary
Jasmine Rose Pearce, aged 11 months, died from suffocation under bedding in her family home on 27 January 2013. Her parents engaged in sexual activity on the bed where Jasmine was sleeping while under the influence of cannabis; her father acknowledged feeling her body beneath him but neither parent checked on her. The sleeping environment was unsafe with an inward-rolling mattress and bedding hazards. Child Protection Services received multiple notifications of family violence and neglect before Jasmine's birth and during her life, but closed these notifications without detailed risk assessment, over-relying on assurances from a Gateway support worker. CPS failed to apply cumulative harm policy despite repeated documented incidents. Critical clinical lessons include: the need for rigorous independent risk assessment regardless of support service involvement, systematic application of cumulative harm frameworks in child protection, documentation of safe sleeping education by support services, and ensuring professional courtesy does not compromise child safety assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- unsafe sleeping environment with inward-rolling mattress and excess bedding
- sexual activity by parents on bed with infant present
- parental cannabis intoxication
- failure to check on infant despite awareness of potential harm
- parents' inability to provide safe care and protection
- inadequate Child Protection Services risk assessment
- over-reliance on Gateway support worker's assurances despite objective evidence of risk
- failure to apply cumulative harm policy
- pattern of family violence exposure
Coroner's recommendations
- CPS conduct regular audits to ensure cumulative harm policy is routinely followed, particularly in cases with repeated family violence notifications
- CPS amend Cumulative Harm Policy to refer to number of separate incidents reported rather than number of notifications as trigger for higher level risk assessment
- CPS continue education on cumulative harm policy practice including strict application, identification of key indicators, extensive investigation, and analysis of full FVMS content
- CPS Intake workers routinely conduct CPIS searches of child, parents and siblings, documenting searches to ensure risk considered across extended periods
- CPS Intake workers provide sufficient written reasoning on risk assessment documents for consistency
- CPS conduct regular audits to ensure TRF is routinely used, CPIS searches conducted, and TRF categories and reasoning clearly documented
- When CPS refers family to Gateway, identify and document case plan for goal achievement on file
- CPS consider strengthening CBTL role to provide further supports and increased capacity given its crucial liaison function
- CPS review point of case closure where notifications involve high-risk family referral to Gateway to ensure independent CPS risk assessment continues until required progress made
- If no progress made by family in Gateway according to case plan and timeframes, refer back to Intake for further investigation
- Conduct regular home visits to families involved with Gateway, attended by CBTL and Gateway worker, to ensure robust investigation into risk
- Include clause in government contracts and Memoranda of Understanding requiring non-government organisations working with infants to discuss safe sleeping practices
- Tasmania Police include training on family violence practices including: eliciting full details of interactions to determine proper categorisation; ascertainment of children in relationship; correct CPIS completion with children's names; supervisory sergeant validation of FVMS completion
- Tasmania Police conduct regular checks to confirm FVMS referrals to CPS are forwarded and received
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