Coroner's Finding: EDWARDS Elizabeth Rose

0y · Female·combined effects of asphyxia and inhalation of gastric contents

Elizabeth Rose Edwards, a 9-month-old premature infant with perinatal brain injury, died of asphyxia and aspiration of gastric contents while in temporary foster care. She had been placed with carers (the Todds) with minimal handover information, no specialist training in infant care, and using a U-shaped pillow in her cot. The coroner found systemic failures in foster care training, assessment, and information transfer, including the absence of mandatory training for carers of infants under two years. The U-shaped pillow was likely instrumental in her death. The case highlights the need for compulsory evidence-based training for all foster carers, particularly those caring for very young children, and better integration between medical providers and child protection services.