Finding into death of Livinia Rose Kenna
Deceased
Livinia Rose Kenna
Demographics
<1y, female
Date of death
2016-04-16
Finding date
2017-02-21
Cause of death
Sudden Infant Death Syndrome (SIDS Category I)
AI-generated summary
Livinia Rose Kenna, a 19-day-old infant, died from Sudden Infant Death Syndrome (SIDS Category I) on 16 April 2016. She was placed to sleep in a bassinet with multiple unsafe sleeping practices: prone positioning, multiple layers of blankets tightly tucked in, additional mattresses creating gaps, and bumpers/objects in the cot. The parents had consumed alcohol the evening of death. A maternal child health nurse conducted a home visit on 5 April but did not visually inspect the cot arrangement despite undertaking a Safe Sleeping Checklist. Post-mortem toxicology detected desmethylvenlafaxine (maternal antidepressant Pristiq) in infant's blood, likely acquired via breastfeeding. The coroner recommended that maternal child health nurses provide thorough visual review of sleeping environments, not just oral advice.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Prone sleeping position
- Multiple blankets tightly tucked in
- Additional mattress creating gaps and unsafe sleeping environment
- Bumpers and objects in cot (dummy, rattle)
- Inadequate visual inspection of sleeping environment by maternal child health nurse
- Parental alcohol consumption evening prior to death
- Possible medication exposure via breastfeeding
Coroner's recommendations
- All Maternal Child and Health Care Nurses should be counselled to provide not only oral advice to families of babies but to also thoroughly review the environment in which the baby is living, including visual inspection of cot arrangements and sleeping practices
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 —