Finding into death of Frankie Skye Foulkes

Contributing factors

• Spinal muscular atrophy type 1 with expected delayed nusinersen benefit
• Fatigue following baby spa session
• Use of standard car seat in absence of appropriate alternative for vulnerable infants
• Positioning in upright car seat causing head flexion and airway compromise
• Respiratory muscle weakness limiting ability to adjust position or take deeper breaths
• Lack of available lie-flat car restraints licensed for use in Australia
• Regulatory framework excluding motor vehicle child restraints designed for children with disability from mandatory safety standards compliance

Coroner's recommendations

1. Victorian Government consider amending Road Safety Road Rules 2017 to include specific authorisation within rule 267 for use of alternative restraints where a child is exempted from approved restraints due to disability or medical condition
2. Standards Australia consider granting exemption to AS/NZS 4370:2013 to Royal Children's Hospital for use of Jane Matrix lie-flat car restraint in its pilot program
3. Australian Competition and Consumer Commission commence review of mandatory standards regarding child restraint systems in consultation with expert stakeholders including Mobility and Accessibility for Children in Australia Ltd, Royal Children's Hospital, TAC, Department of Transport and Planning, and interstate equivalents, to develop standards for safe special purpose car restraints and revise existing standards to facilitate broader availability of car restraints for children with complex medical conditions and/or disability