The death of a three-month-old baby was caused in part by the child being placed in an "unsafe sleeping position" in a cot, a coroner says.
While details of the case, such as the name of the baby, cannot be published, Judge David Robinson believes publicity about the circumstances of the death could potentially promote awareness of safe sleeping practices.
According to the coroner's findings, in August 2019, the Christchurch child became slightly unwell with a hot head but cold feet. After the young girl cooled down, she was placed in her cot and became "grizzly" after about 10 minutes. Her mother picked her up and the baby fell asleep on her chest.
While the child had an "alright" afternoon, in the evening, she would only settle on the mother's stomach. Early the next morning, the father placed the child into her cot "in a position that tried to mimic the way in which [the baby] had fallen asleep [on the mother] earlier that night".
The father said he had placed the child in the cot, on a pillow, lying on her stomach, with her hands stretched out in front of her, and her head angled on the right side with her left cheek on the pillow. He also used a blanket to "help lay her on her side slightly to keep her from being face down".
Sometime later, the father checked in on the baby and found her "lying face down on the pillow" and that she "seemed yellow". Realising the child wasn't breathing, the father alerted the mother and called emergency services. He also conducted CPR described as "of a high standard" while the ambulance was on its way.
"Through that CPR, [the father] gave [the baby] the best chance of survival. Unfortunately, notwithstanding the best efforts of [the father] and emergency services, [the baby] could not be revived."
A forensic pathologist found the cause of death was sudden unexpected death in infancy (SUDI) "in the context of an unsafe sleeping positioning". The baby also had a viral infection that wasn't the direct cause of death but "may well have complicated upper airway breathing", potentially contributing to the death.
The SUDI appeared to be a breathing issue, the pathologist found, "with the consequence that anything that makes breathing more difficult (such as infection or a facedown sleeping position) could make a SUDI more likely". He said a soft sleeping surface "could have significance as such surfaces could, depending on the position of the baby, spread around the face, potentially either causing an obstruction or some retention of carbon dioxide".
The coroner says police found there was nothing suspicious about the baby's death while nothing indicated "there was any evidence of her developing a serious illness such that earlier medical intervention was warranted".
Judge Robinson said while the father was right to settle the baby in her own cot, placing her on her stomach on a pillow was an unsafe sleeping positioning, but he fully understood the father's "well-intentioned attempt" to settle the baby.
"I don't criticise [the father]. He was doing his best to settle his baby. If one positive could be taken from this case, it would be that the circumstances allow a timely reminder to mums and dads of the importance of putting babies into their cots on their backs."
He endorsed similar advice from the Ministry of Health saying babies should sleep on their backs keeping their airways clear and in their own cots or beds. That advice can be found here.
