Finding into death of Hailey Holmes
Deceased
Hailey Holmes
Demographics
5y, female
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.
Error types
Clinical conditions
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
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 —