Coroner's Finding: Lukendlay, Charlotte (OM) Findings
Deceased
Charlotte Lukendlay
Demographics
0y, female
Date of death
2016-02-25
Finding date
2019-06-26
Cause of death
global hypoxic brain injury caused by prolonged cessation of breathing arising from an act done by her father
AI-generated summary
An 11-week-old healthy infant died from global hypoxic brain injury following cardiac arrest at home. Multiple rib fractures and a clavicle fracture in various stages of healing indicated repeated non-accidental trauma inflicted by her father over weeks. The father placed the infant in unsafe sleeping positions (prone, tightly wrapped) despite knowledge of safe sleeping practices and warnings from the mother and his own parents. He had a documented pattern of violence, alcohol abuse, and expressed desire to harm the child. The mother was unable to protect the infant due to intimate partner violence and control. Key clinical lesson: healthcare providers must recognise patterns of intimate partner violence in families with infants, recognise and document non-accidental injuries (including healing fractures), and escalate child protection concerns proactively. The infant's healthcare visits identified no injuries, but safe sleeping practice education was provided without recognition of the broader family violence context.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- non-accidental trauma inflicted by father
- unsafe sleeping position (prone, tightly wrapped)
- repeated rib and clavicle fractures indicating abuse
- father's knowledge of safe sleeping practices but deliberate disregard
- intimate partner violence preventing mother from protective intervention
- alcohol abuse by father
- father's expressed desire to harm the child
- lack of external oversight of home environment
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