Inquest into the Death of West

8y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping (bed sharing)

Nathaniel West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006. The infant was discovered unconscious under his mother's breast on the morning of 30 April after an unobserved period of co-sleeping during the night shift. Despite resuscitation and transfer to Princess Margaret Hospital, irreversible brain damage had occurred. The hospital had no formal co-sleeping policy in 2006, staff were not adequately educated about co-sleeping risks, and risk factors specific to this case (young, fatigued, difficult-to-rouse mother; newborn under 11 weeks) were not actively managed. The coroner found the death was accidental but preventable through proper policy, staff education, and active discouragement of high-risk co-sleeping.