An eight-month-old who had been in the care of a Child Youth and Family caregiver for a week died suddenly when she became tangled in the blankets she was sleeping in, a coroner has found.

Alexis Green had been urgently placed into the care of Child Youth and Family (CYF) in Christchurch on October 4 last year after police were called to her 23-year-old mother's home three times in one night.

For six years the Ministry of Social Development (MSD) had been aware of Alexis' mother, whose six children had been in and out of CYF care.

On October 4 Alexis was urgently placed into a CYF caregiver's care, a coroner's report released today (Wed) said.


The caregiver, identified only as Ms A, had been assessed as being a suitable caregiver in September 2009 and a review in September last year recommended that Ms A was best suited to provide transitional care for 7 to 10-year-old girls, Coroner Sue Johnson said.

The social worker who carried out this assessment did not transfer her recommendation to the computer system.

On October 4, when another social worker looked at Ms A's file, she saw nothing about the age recommendation.

On the night of October 10, Ms A put Alexis to bed on her back and with three cot blankets placed over her. The blankets were not tucked in.

Later in the evening Ms A checked on Alexis and put two extra blankets on her and pulled the blankets up to her chest.

At 7am the next day, Ms A found Alexis face down with the blankets tight over her head with her knees pulled up under her body.

Ms A saw that Alexis was purple and called emergency services but she was pronounced dead.

Forensic pathologist Martin Sage determined Alexis died of sudden unexpected death in infancy due to accidental asphyxia in an unsafe sleeping position.

Since Alexis' death a CYF practise review was commissioned and completed. It recommended that whenever caregivers were assessed or reviewed, a CYF worker must sign off that notes about the assessment were on the computer database.

Since the report was commissioned staff had taken action to remedy unsafe sleeping arrangements after talking with caregivers, Coroner Johnson was told.

Kelly-Marie Anderson, the regional director of the southern region of CYF, said CYF was now expert at developing policies to respond to child abuse and neglect but it was not expert in terms of policies about general safety and well-being and health of children.

Ms Anderson was hopeful that with external expert assistance the Ministry could implement national requirements for safe sleep practises and environments for babies in CYF care.

Coroner Johnson compiled a vast list of recommendations for her report, released today, aimed at the MSD, the Ministry of Health and the Social Workers Registration Board.

The recommendations included:

* The MSD develop national pro-active policies which would embed knowledge, understanding and skills about safe sleeping practises into the day to day business of CYF.

* MSD seeks external advice about how to educate CYF social workers and caregivers.

* Staff and caregivers receive regular training.

* That MSD sets a goal to have all placements for babies smokefree.

* That the Ministry of Health launches an advertising campaign to promote safe sleeping principles.

Between July 2007 and April 2012 there was 212 sudden infant deaths in New Zealand.

In 30 of those cases a coroner found that the death was caused by asphyxiation during unsafe sleeping.