A 10-week-old baby girl was let down by the very ministry dedicated to safeguarding her, a coroner has concluded.
The cause of death for the baby known as Te Whetu was sudden unexpected death in infancy (SUDI) while bed-sharing, after her mother found her unresponsive on the morning of Monday 5 August 2019, in a Linwood flat in Christchurch.
Te Whetu was unable to be revived.
While SUDI was the cause of death, Coroner Sue Johnson noted that Te Whetu was let down by Oranga Tamariki (OT), by not having support and assistance provided for her family at the earliest opportunity, and not acting on ‘’red flags’’ raised by medical professionals.
OT responded by strengthening its case transfer process both within and across regions, and updated its guidance to frontline OT practitioners on safe sleeping.
The coroner commended OT for making changes and proposing upcoming changes to its processes and practices.
‘’I consider that the changes once embedded will go some way to prevent future deaths occurring in the same circumstances as Te Whetu’s occurred.
‘’Te Whetu’s 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.’’
The baby girl was born five weeks early in Southland Hospital, the only child of her parents.
Initial concerns about the care of the baby, saw the case referred to Oranga Tamariki for assessment.
Later, when she was just six weeks’ old, Te Whetu and her mother were transferred to Christchurch’s Princess Margaret Hospital, for the latter to have her mental health assessed.
At the start of that admission, her mother was educated about the risks of co-sleeping, and given a pēpi-pod for her daughter to sleep in.
On six occasions, Te Whetu was found in her mother’s bed and moved by staff into the pēpi-pod. Each time this occurred, her parents were reminded by staff about the risks of co-sleeping.
UNSPLASH
When she was just six weeks’ old, Te Whetu and her mother were transferred to Christchurch’s Princess Margaret Hospital, for the latter to have her mental health assessed.
While in hospital, concerns were also raised about the mother, including leaving the baby unsupervised in the bath, using alcohol and cannabis, and lacking engagement.
On July 21, 2019, the mother discharged herself and Te Whetu from hospital a week earlier than their planned discharge date. Being a Sunday there were no medical staff available to review them prior to discharge. The family did not attend a planned review the next day.
The young family stayed in Christchurch, settling into temporary accommodation in New Brighton. Attempts by the hospital to contact the mother went unanswered.
Meanwhile, a supervisor asked that a social worker urgently visit the young family. A follow-up home visit was completed that same day by a Christchurch-based OT social worker.
On July 25, the mother took Te Whetu, now eight-weeks old, to a doctor for her six-week baby check and immunisations. The GP was concerned about the mother’s detachment, poor interaction and handling of her baby.
Later on August 2, the family moved to a flat in Linwood with some others, including the godmother, and took the pēpi-pod with them.
The baby usually slept in that pēpi-pod between her parents, but when Te Whetu was unsettled they would bring her to lie between them in their bed, or they put her on top of either of them.
At one point the godmother found Te Whetu lying on the bed with her head hanging off the edge.
Several days later she was woken by the mother crying, yelling and tapping her on the shoulder saying Te Whetu would not wake up.
She found the baby unresponsive and alone on the bed with no blankets on her.
Te Whetu was unable to be revived by paramedics.
A pathologist’s opinion was that the cause of Te Whetu’s death was sudden death while bed sharing.
The baby’s GP was of the opinion that there had been “a significant system failure” which played a role in her death, including a lack of a discharge summary from the hospital.
The coroner noted that it was disappointing that the file concerning the young family was not transferred from Southland to the Christchurch OT office sooner.
‘’OT’s response to the unfolding events concerns me.’’
OT should have been aware that Te Whetu was at ‘’significant risk of harm’’.
The whānau’s decision to move from Gore to Christchurch resulted in a very slow transfer process between OT offices at a critical point in time for Te Whetu.
‘’I consider that Te Whetu was let down by the very Ministry dedicated to safeguarding her.’’
Three days before she died, a Gore social worker found that the safety plan was no longer in place, the mother was no longer living with her supervisor, and a flatmate living with the family had an extensive alcohol, drug, and criminal history.
