Coroner's Court of Western Australia

Inquest into the Death of Baby A (Subject to Suppression Order)

Inquest into the Death of Baby A (Name Subject to Suppression Order)

Delivered on :23 August 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes


I recommend that WACHS give active consideration to implementing a culturally appropriate safe sleeping space took, such as the Pepi-Pod, in regional WA Hospitals, following the lead set by New Zealand the Queensland Government.

Orders/Rules : N/A

Suppression Order : Yes

The suppressing the deceased’s name for the purposes of publication. The deceased is generally referred to as Baby A or the baby throughout the finding.

Summary : The deceased at the time of his death was in hospital with his mother having been treated for a number of medical problems common to premature babies. He was found by medical staff unresponsive and co-sleeping with his mother in bed.  He was 8 weeks old.

The inquest focused primarily on the events that occurred at hospital and the issues surrounding co-sleeping. The Coroner used the term ‘co-sleeping’ to describe the practice of parent/carer and baby both sleeping at the same time on the same bed surface.

The deceased was born prematurely at a remote Aboriginal Community. Following his birth he was taken by ambulance to the nearest local hospital and a paediatric team flew in from Broome to care for him.  It was identified that he would require longer term medical care and he was transferred to Darwin Hospital by Royal Flying Doctor Service and his parents followed.  He was treated for a number of medical problems including hyaline membrane disease, jaundice, low sodium levels and feeding issues.  Once his condition improved arrangements were made to transfer him to Derby Hospital so that he and his parents would be closer to home.  He would remain in the Derby Hospital for further monitoring of his weight and to provide support for his mother until he was considered sufficient weight to be safe to go home.

On arrival at the Derby Hospital he was examined and noted to be a healthy baby who was breastfed with bottle top ups. He was approximately 7 weeks’ old.  He was admitted to the ward that evening with his mother.  During the night he was found co-sleeping with his mother a number of times, contrary to the advice of the midwife.  He was moved back to his cot by the midwife on each occasion.  The following morning another midwife entered the room and found that the deceased was again asleep with his mother in the hospital bed.  She did not wake them and left the room.  When the midwife returned a few hours later the deceased was breastfeeding.  The deceased was also seen by the doctor around this time and noted that he appeared to be active and feeding normally.

A different midwife entered the room about an hour later and found the deceased co-sleeping with his mother in the bed. She approach him and found he showed no signs of life.  Vigorous resuscitation attempts were made but the deceased could not be revived.

The Court heard evidence on the policies of co-sleeping which WACHS have in place with respect to the issue of co-sleeping in hospital maternity wards. The Court heard evidence of Aboriginal women and the cultural practice of co-sleeping and the difficulties faced by staff in communicating the safe sleeping message to patients who have a strong cultural preference.  The Court was advised that the Derby Hospital had been exploring more culturally appropriate ways of delivering the safe sleeping message to parents since Baby A’s death.  The Court was advised WACHS was looking at a Pepi-Pod program that was being trialled through the University of Sunshine Coast in Queensland.  A Pepi-Pod is a safe sleeping box which can sit in the bed so that the baby can be in the bed with his or her parent without the risk that the parent will roll over onto the child or become caught in the bedding.

The Coroner made a recommendation in relation to the Pepi-Pod to improve and educate the cultural practice of co-sleeping.

Catch Words : Co-sleeping : Pepi-Pods : Education for parents on ‘safe sleeping practices : Accident.

Last updated: 30-Apr-2019

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