Coroner's Finding: de-identified FG

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, youths and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Olivia McTaggart, Coroner, having investigated the death of FG Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is FG, date of birth 20 December 2022.

b) FG was a 59-day-old infant when he died. He was the son of TU and KL, and brother of QR (a sister, born 2020). The family lived in a three-bedroom house in Montello, Burnie. FG was born prematurely and did not have any health issues. Both TU and KL were very fatigued after FG’s birth. They struggled to get him to sleep and they had limited family support except for TU’s uncle and auntie.

On the evening of 16 February 2023, TU’s uncle and auntie took QR for the night so that TU and KL only had to care for FG. At 6.00am the following morning, KL fed FG his usual formula and left for work at 7.00am. TU was awake and placed FG in his cot. She then lay down on a single mattress which was positioned directly against his cot in his room. However, FG would not settle and therefore TU took him out of his cot and placed him, on his back, onto the mattress next to her. At that time, she lay on her right side facing both FG and the cot, placing one hand under the pillow and one hand between her legs. She told investigating police officers that this was a practice she had learned from her mother in order to stop herself rolling over onto the infant.

At 1.30pm KL returned home from work for lunch. He found TU asleep on the mattress, roused her and then went outside to smoke. Whilst KL was outside, TU realised that she was now facing away from the cot and had rolled over. She then noticed that FG was pressed against her back, he was pale and cold, and was bleeding from the nose. She believed that he was likely deceased. She and KL called for an ambulance and commenced CPR. The paramedics took over

upon their arrival, although FG could not be resuscitated and was pronounced deceased. When police officers attended the scene to investigate the FG’s death, they found no suspicious circumstances.

c) I find upon the evidence that the cause of death was suffocation due to overlay by a sleeping adult. I find that at a time between about 7.00am and 1.30pm, whilst TU was sleeping next to FG on a single mattress, she unintentionally rolled onto him, tragically causing his death. There were no other contributory causes of his death.

d) FG died on 17 February 2023 at Montello, Tasmania.

In making the above findings, I have had regard to the evidence gained in the investigation into FG’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits confirming identity;

• Opinion of the forensic pathologist who conducted the autopsy;

• Toxicology report of Forensic Science Service Tasmania;

• Medical records;

• Affidavits of three attending police officers, including a CIB detective and a forensics officer, together with scene photographs;

• Body worn camera footage of three police officers, containing the accounts of FG’s parents regarding the circumstances of his death;

• Sudden unexpected death in infancy report; and

• Records of Tasmania Police.

Comments and Recommendations Over the years, coroners and health professionals have constantly emphasised the dangers of adults co-sleeping with infants. This practice continues despite parents being aware of the risks. In this case, FG would not have died if he had been in his own cot.

I again emphasise the critical importance of putting infants to sleep in their own cot or safe sleep surface at all times in order to reduce the risk of sudden infant death.

I extend my appreciation to investigating officer Constable Brett Jones for his investigation and report.

I convey my sincere condolences to the family and loved ones of FG.

Dated: 19 October 2023 at Hobart in the State of Tasmania.

Olivia McTaggart Coroner