Inquest into the Death of West

Contributing factors

• absence of hospital co-sleeping policy in 2006
• inadequate staff education about co-sleeping risks
• failure to recognise and actively manage high-risk co-sleeping circumstances
• young mother (18 years old) with history of substance abuse and seizure disorder
• mother's extreme fatigue and tendency to be difficult to rouse once asleep
• busy night shift with limited midwifery staffing (two midwives for both maternity and labour wards)
• baby left unsupervised in bed with drowsy mother during breast feeding
• inappropriate support person (14-year-old) sent with mother from Warburton
• mother's limited parenting skills and understanding of safe baby handling
• uncoordinated response from Department of Community Development
• late provision of antibiotics to mother on morning shift

Coroner's recommendations

1. SIDS and Kids remove the current Safe Sleeping National Brochure from distribution and replace it with one more in line with contemporary medical knowledge with respect to the risks associated with co-sleeping
2. KRH actively promote its own policy based on the Health Department Operational Directive and Clinical Guidelines with respect to safe sleeping practices by way of formal training and education of midwife/nurses to ensure implementation and consistency of education by example for its patients
3. Hospitals be required to show they have implemented the Health Department Operational Directive (139/08), including co-sleeping should be avoided if the baby is under 11 weeks of age, before they can be accredited as baby friendly
4. Resources be provided to country hospitals in particular to encourage staff participation in education from either the Health Department with respect to Operational Directive 0139/08 or SIDS and Kids as to safe sleeping practices for babies by way of funding for back filling of staff attending such education
5. Medical practitioners understand and use terms associated with the sudden and unexpected death of infants (SUDI) with care to promote an understanding of the complexity of issues involved in unexpected baby deaths
6. Health practitioners avoid the use of the term 'cot death' and show great care in using the term 'SIDS' in order to assist the public in understanding the complex issues involved in unexpected baby deaths