Inquest into the Death of BENFIELD

Contributing factors

• Prematurity (born at 33 weeks gestation)
• Co-sleeping with father
• Parental smoking history
• Maternal illicit drug and alcohol use history
• Hyperthermia (warm bedroom environment, approximately 30 degrees Celsius)
• Infant repositioned to prone position during sleep
• Lack of education about SIDS risk factors provided to caregivers
• Maternal untreated severe mental illness (schizophrenia)
• Inadequate child protection response by Department for Child Protection
• Placement with unsuitable caregiver without assessment
• Parental incarceration and forced separation from infant

Coroner's recommendations

1. The Department for Child Protection in the Goldfields should offer the Best Beginnings program (or any subsequent similar program) to all new parents with whom the DCP has dealings so that the program draws the widest participation from the broadest range of the population, particularly those parents whose circumstances are challenging.
2. WA Health should work with other stakeholders (Community Health Nurses, the Department of Child Protection, Aboriginal Medical Health Providers, SIDS and Kids and other interested groups) to develop and transmit a coherent message relating to the known risks that can cause unexpected infant mortality, delivered in a culturally appropriate and relevant way to Aboriginal parents.
3. The Department of Health should develop a Tab in its purple book (or subsequent iteration) that gives parents advice about sudden infant deaths, the factors reasonably thought to be associated with those deaths, and practical advice on reducing risks, including information about safe sleeping arrangements, risks of second-hand smoke exposure, and risks of keeping a child in an environment that is too warm.