Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

Contributing factors

• unsafe co-sleeping in adult bed with sedated parent
• infant placed on side/prone against pillow, not supine
• parental sedation and drug intoxication
• high level of environmental smoking in home
• infant's mild bronchiolitis and respiratory infection
• infant's small size for age
• failure of child safety services to remove infant from high-risk home
• premature closure of unborn baby notification without risk assessment
• inadequate reunification planning for older sibling with known injuries
• failure to conduct comprehensive risk assessment despite documented non-accidental injuries to older child
• poor home conditions including poor hygiene

Coroner's recommendations

1. Upon CSS becoming aware of the death of a child where that child, his/her parents or siblings are known to CSS within 3 years prior to the date of the death, CSS should advise the Coroner's Office of the death and provide a brief summary of its past and current involvement with the child and family members
2. CSS should review its policy 'Reporting the death of a child in care to the Coroner' with a view to including provisions to accord with the above recommendation
3. Tasmania Police should notify CSS of the death of any child the subject of a report to the Coroner so as to enable CSS to provide details to the Coroner
4. CYS and CSS should provide to the Coroner a copy of any review undertaken by it or at its request in respect of a child whose death has been reported to the Coroner as soon as that review is completed or within a period of 90 days, whichever is the earlier
5. CSS should provide training on an ongoing basis to its child safety officers in effectively identifying and responding to situations where it is identified that an infant under the age of 12 months may be at risk due to unsafe sleeping practices