Sudden death in Christchurch: no blame on ‘traumatized’ parents, but coroner pleads for safer sleep for kiwis

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A Christchurch baby has died after being put to bed in his crib. Photo / 123RF image file

A coroner has urged parents to make sure they follow safe sleep advice after the tragic death of a Christchurch baby from sudden death.

The 3-month-old girl died in 2019 and her case has been referred to the coroner.

Her name – along with the names of her parents – have been deleted to protect their privacy.

Coroner David Robinson made no specific recommendations, but approved the Department of Health’s guidelines for safe sleep in an effort to prevent sudden and unexpected future child deaths (Sudi).

He was quick to say that the investigation process for the little girl was not about “blame.”

“Rather, it is about achieving a full understanding of the cause and circumstances of the death of a loved one,” he said.

“It can bring comfort and understanding to the immediate family and can also benefit the community at large if the case allows recommendations to be made that may reduce the risk of further death in similar circumstances.”

He said the baby died in his cot at the family home.

She had a viral infection – probably respiratory – at the time and while it was not a direct cause of death, it may have complicated and contributed to her breathing.

Robinson said his official cause of death was Sudi “in the context of an unsafe sleeping position”.

“My conclusion was that [she] was placed on the bed to sleep on the front, on a pillow with the head to the side, ”he said.

The baby was 89 days old (12 weeks old) when she died.

No major health problem led to his death.

“[She] was clearly fine, ”said Robinson.

“[Her mother] said she was active, loved bath time and tummy time – she was strong and was able to hold her head up. “

The day before her death, she became “a little sick”.

She was unstable and was not his “normal self”, but she was eating well.

That night, her mother said she planned to have to take her to the hospital.

Soon after, the baby fell asleep in his mother’s arms.

In the early hours of the next morning, her father placed her in his cot on the pillow – in the same position she was lying on top of her mother.

He used a blanket to lightly support the baby to the side to “keep him from being face down on the floor.”

Shortly after, he returned to see her and found that she was no longer breathing and yelled at his wife to call for an ambulance.

While the couple in distress waited for help, the father performed CPR on the baby, assisted over the phone by an operator from 111.

“Unfortunately, despite the best efforts of [the father] and emergency services personnel [the baby] could not be revived, ”said Robinson.

He said the father’s decision to place the baby on the pillow made sense to him but was not ideal.

“He was right in trying to get her into his own bed. As a father with a lot of experience of sleepless nights with sick grizzly babies, I can fully understand his well-meaning attempt to settle down. [the baby], imitating his sleeping position on [her mother],” he said.

“What we’ve learned from studying Sudden Infant Death Syndrome is that the best position for babies is always to sleep in a crib lying on their back without pillows.

“I’m not criticizing [the father] – he was doing his best to calm his baby.

“If a positive point could be drawn from this case, it would be that the circumstances provide a timely reminder to moms and dads of the importance of putting babies to sleep in their cribs on their backs.”

Robinson agreed to remove the names of the baby’s parents in the interests of “justice, privacy and decency.”

He said they were traumatized and having their names made public would undoubtedly cause “continuing distress”.

He added that although the coronary jurisdiction was “designed to be therapeutic in nature,” he also had a duty to the public regarding the safety of children, so he allowed the media to publish his findings.

“There is a legitimate public interest in the well-being of our children, especially where there are steps that can be taken to reduce the potential for negative outcomes,” he said.

“The circumstances of [the baby’s] death could potentially promote awareness of safe sleep practices. “

Make every sleep a safe sleep – advice for parents

Comprehensive advice for all babies is available on the Department of Health website

Information on the use of pepi pods can be found on the same website.

Sudden and unexpected death is a risk for babies up to about 12 months of age, but most deaths are preventable.

There are things we can do to protect our babies.

Although for some babies the cause of death is never found, most deaths occur when babies sleep unsafe.

Always follow these safe sleep routines for your baby and his bed.

To keep your baby safe while he sleeps, make sure you:

They always sleep on their backs to keep their airways clear

They are in their own crib, cradle, or other crib (for example, a ppi-pod or wahakura) away from adults or children who could accidentally suffocate them

They are put back in their bed after feeding do not fall asleep with them (to protect your back, feed your baby in a chair rather than in your bed)

They have someone caring for them who is attentive to their needs and free from alcohol and drugs

They have clothes and bedding that keep them at a comfortable temperature. One more layer of clothing than you would do is enough; too many diapers can make your baby warm and upset him

They are in a room where the temperature is maintained at 20C.

The crib is safe when:

It has a firm and flat mattress to keep your baby’s airways open

There is no space between the bed frame and the mattress that could pinch or pinch your baby

Nothing in the crib can cover your baby’s face, lift their head, or suffocate them No pillows, toys, loose bedding, cushions or necklaces (including amber beads and necklaces). “teething” necklaces)

Where to get help:

If you’re worried about your mental health or someone else’s, the best place to go for help is your GP or local mental health care provider. However, if you or someone else is in danger or endangering others, immediately call the police on 111.

OR IF YOU NEED TO TALK TO SOMEONE ELSE:

LIFELINE: 0800 543 354 or 09 5222 999 in Auckland (available 24/7) SUICIDE CRISIS HELP LINE: 0508 828 865 (0508 TAUTOKO) (available 24/7) YOUTHLINE: 0800 376 633 , Free SMS 234 or email [email protected] .nz or online chat. NEED TO TALK? Free call or SMS to 1737 (available 24/7) KIDSLINE: 0800 543 754 (available 24/7) WHATSUP: 0800 942 8787 (1 p.m. to 11 p.m.) DEPRESSION SUPPORT LINE: 0800 111 757 SAMARITAINS 0800 726 666.

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