“Support and assistance were not provided for her family at the earliest opportunity, and the concerns raised by medical professionals were not addressed, and a number of red flags were missed.”
The baby died in August 2019. Her mother, who had shared a bed with her, woke to find her unresponsive. Emergency services were called, but it was too late.
A police investigation found no criminal liability.
The cause of death was ruled by Coroner Johnson to be sudden unexpected death in infancy while bed-sharing. The infants’ parents later said co-sleeping was a way of bonding with their baby.
Other conditions identified were bronchopneumonia, aspiration, and candid and possible sepsis. However, it was ruled they did not directly relate to her death.
When the girl was born, she was five weeks premature. Despite her premature birth, she had no health complications, but her mother had suffered from significant mental health issues.
A referral was made to Oranga Tamariki by the mother’s midwife a month after the birth. She said the baby was at risk, living with a mother who allegedly used drugs and suffered from mental health issues.
Despite the referral leading to Oranga Tamariki investigating the situation, the family had moved around and communication between offices meant there was a breakdown in information sharing.
The mother had attempted suicide three weeks after the birth and spent time in mental health facilities. At one point, the baby was living with the mother in one such facility, where the dangers of co-sleeping were discussed on several occasions.
Unsafe bed-sharing practices were a constant concern for medical professionals, who notified Oranga Tamariki about the issue.
Safe practices were encouraged, as well as education on the dangers of co-sleeping and smoking around the infant, but this was not heeded by the mother. The report states this was known by Oranga Tamariki.
A safety plan was put in place by Oranga Tamariki and medical professionals, but this was not followed up by the agency.
Coroner Johnson said the infant and her family were not sufficiently supported by the agency.
“OT did not ensure [the baby] or her whānau had the right level of support in place. Her safety was never properly assessed.
“The system did not work in the way it should have and [the infant] and her whānau were left unsupported as a result.”
Coroner Johnson acknowledged the changes Oranga Tamariki had made, or were in the process of making, since the baby’s death.
She said a review was under way with an emphasis on communication and information sharing.
“I commend OT for making changes and proposing upcoming changes to its processes and practices in order to safeguard pēpi.
“I consider that the changes, once embedded, will go some way to prevent future deaths occurring in the same circumstances as [the infant’s] occurred.
“[Her] death is a tragic reminder that there is an ever-present danger of death of a pēpi, when placed to sleep in a co-sleeping environment.”
Oranga Tamariki acting chief executive Phil Grady acknowledged the findings, saying the agency should have done better in protecting the baby.
“The death of any child is devastating, and I would like to firstly acknowledge the whānau involved, who loved this pēpi.
“We accept that we did not act quickly enough at critical points and failed to note multiple red flags throughout the time our organisation was involved.”
He said several changes have now been made at a local level between the two sites involved in the care of the baby.
Oranga Tamariki’s case transfer policy was also strengthened in October 2022 to place a greater focus on communication and information sharing, and this year, new guidance was given for working with tamariki under the age of 5.
“We know there is always more work to be done, and we are committed to continuing this so every whānau and tamariki in Aotearoa can live and thrive.”
Hazel Osborne is an Open Justice reporter for NZME and is based in Te Whanganui-a-Tara, Wellington. She joined the Open Justice team at the beginning of 2022, previously working in Whakatāne as a court and crime reporter in the Eastern Bay of Plenty.
