Coroner's Finding: BR - deidentified
Demographics
0y, female
Date of death
2021-02-12
Finding date
2022-02-23
Cause of death
Undetermined - coroner unable to determine exact cause; unsafe sleeping environment with risk of suffocation by adult bedding or overlaying by other occupants considered major contributing factor
AI-generated summary
A 5-month-old infant died suddenly in a co-sleeping environment with adults and a toddler in a queen-sized bed with adult bedding. Autopsy revealed no definitive cause but identified significant risk factors: unsafe sleeping conditions with risk of suffocation, rhinovirus infection, and nicotine exposure. The infant had received appropriate health checks and vaccinations. Parents had been advised on safe sleeping practices by child health nurses on three separate occasions, recommending baby sleep in a safe cot in parents' room. The coroner found the unsafe sleeping environment contributed to death and emphasised that the infant would likely have survived with appropriate sleep arrangements. This case highlights the continuing tragedy of preventable sudden infant deaths from co-sleeping despite well-established safety guidance.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- co-sleeping with adults and toddler in unsafe sleeping environment
- adult bedding (doona and pillows) in bed with infant
- rhinovirus infection
- nicotine exposure from maternal smoking
- chronic aspiration (identified at autopsy)
Coroner's recommendations
- Emphasis on critical importance of putting babies to sleep in their own cot or safe sleep surface at all times to reduce risk of sudden infant death
- Reinstatement of public health messaging regarding fatal risks of co-sleeping with infants
Full text
Related cases
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —