Coroner's Finding: Infant W and Infant P

Contributing factors

• co-sleeping in adult bed with excessive bedding
• inadequate child safety services risk assessment
• delay in case allocation (approximately two months)
• failure to provide safe sleeping education by CSS
• parental substance use (alcohol, methadone, tobacco)
• parental mental health issues and family violence
• absence of unborn baby alert for Infant P despite high-risk classification
• lack of protective court orders
• parental disengagement from family preservation program
• excessive room temperature and cigarette smoke exposure (Infant P)
• prematurity and low birth weight
• inadequate communication between CSS, CHaPS, and hospital services

Coroner's recommendations

1. CSS to revisit unborn baby alert procedures and processes regularly to ensure clarity and consistent statewide administration, with evaluation in staff training programs
2. CSS to revisit infant safe sleeping procedures and processes regularly to ensure clarity and consistent statewide administration, with evaluation in staff training programs
3. CSS to undertake regular audit processes to determine whether safe-sleeping messages have been delivered to families in accordance with procedure, with implementation of further training as needed
4. CSS to require contracted community sector organisations to deliver safe sleeping information to CSS-referred families and notify CSS of any observed unsafe sleeping practices
5. CSS to ensure that when engaging community sector organisations, roles, responsibilities, and critical timeframes are clearly specified
6. CSS and CHaPS to implement a joint plan to consult and share information in cases where infants are subject to CSS involvement, to maximise safety in sleep environment
7. Community sector organisations delivering intensive programs to high-risk families with infants to establish training modules for staff on infant safe sleeping, including delivery of safe-sleeping messages
8. Serious Event Review Team to be re-established or alternative body created comprising appropriately qualified persons to review CSS practice in cases involving deaths of children involved with CSS
9. Tasmanian Health Service to complete evaluation of 2020 Pepi-Pods trial and, if indicated, implement statewide rollout to parents or caregivers whose infants may be at risk
10. Safe-sleeping education to incorporate information about the narrow size of infant airways and high correlation between SUDI and cigarette smoking, including smoke transference risk