VIChome

Finding into death of Hailey Holmes

Deceased

Hailey Holmes

Demographics

5y, female

Coroner

Coroner Caitlin English

Date of death

2011-06-01

Finding date

2014-11-28

Cause of death

Sudden Infant Death Syndrome Category II

AI-generated summary

A 5-month-old infant died from Sudden Infant Death Syndrome (SIDS II) after being placed prone to sleep in a portable cot with additional bedding including thick blankets, a foam couch mattress, and rolled blankets to fill gaps. The coroner found that the sleeping environment posed suffocation risks, particularly due to ill-fitting mattress and additional soft items. Maternal and child health nurses had advised the mother about safe sleeping position (supine) at a February 2011 appointment, but this advice was not heeded. The coroner emphasised that health professionals must consistently address safe sleeping at every appointment, particularly regarding transitioning between sleeping environments and the dangers of adding extra mattresses or padding to portable cots, which creates potential suffocation hazards.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsemergency medicineobstetricsforensic medicine

Error types

communicationsystem

Clinical conditions

sudden infant death syndrome

Contributing factors

infant placed in prone sleeping position
portable cot used as permanent sleeping environment
additional bedding items in portable cot (thick blankets, foam mattress, rolled blankets)
ill-fitting mattress creating gaps
parental non-adherence to safe sleeping advice
inconsistent reinforcement of safe sleeping guidance at maternal and child health appointments

Coroner's recommendations

That maternal and child care nurses address the issue of safe sleeping, including the transition to different sleeping environments, at every 'Key Ages and Stages' appointment with infant's caregiver
That maternal and child care nurses continue to educate caregivers about the suffocation dangers of using extra mattresses or padding in portable cots
That the Australian Competition and Consumer Commission include a mandatory warning on all portable cots that they should only be used for temporary use only and are not suitable for long term or permanent sleeping arrangements

Full text

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