Morwell baby died at 7 weeks with cocktail of drugs in system, coroner’s probe hears
A baby born to drug-abusing parents, who suffered a black eye in his first month of life and was dead with a cocktail of drugs in his system at seven weeks, was judged not at “significant risk” by child protection authorities.
Police & Courts
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A seven-week-old baby whose family was the subject of repeated child protection notifications died with a cocktail of drugs in his system just over two weeks after a warning that he and his sibling were being neglected.
Child protection authorities had only just started investigating the Morwell family of “Baby B”, who cannot be named for legal reasons, when he died in December 2020, despite staff at The Royal Women’s Hospital raising concerns about his welfare from before he was born, Coroner Audrey Jamieson found this week.
An autopsy report found the boy died with eight drugs including methylamphetamine, oxycodone, tramadol and heroin metabolites in his system, believed to have been ingested through breastmilk, formula or via “environmental contamination”.
The infant was found unresponsive in bed while co-sleeping with his drug-abusing mother and stepfather, whom authorities ordered to stay away from the boy.
The autopsy revealed signs of potential smothering but could not determine the baby’s exact cause of death or any role the drugs may have played.
It found the boy died of Sudden Infant Death Syndrome (SIDS) category 2, which refers to the sudden death of babies during sleep where suffocation or mechanical asphyxia cannot be determined or excluded with certainty.
Fears for the baby began well before his life started, with reports made to authorities his mother was using drugs while 20 weeks pregnant.
Staff at the Royal Women’s Hospital made an ‘unborn alert’ for him prior to his birth to ensure child protection authorities were aware of the harms he would come to face.
At just four weeks of age, the boy was seen with a black eye, and numerous reports were made about he and his sibling’s exposure to family violence, parental substance abuse, lack of supervision and parenting capacity.
Child Protection, in consultation with Lakidjeka, the Victorian Aboriginal Child Care Agency, undertook a risk assessment and found the baby and his sibling were not at significant risk in their mother’s care, subject to her entering a protective agreement plan.
The plan included the children having no contact with their stepfather or being exposed to family violence or substance misuse.
Both aspects of the plan were ignored the morning of the baby’s death, which highlights the dangers of co-sleeping, especially when drugs are involved.
In the past 15 years, 163 Victorian infants have died while co-sleeping – equivalent to 10 deaths every year, shocking new figures reveal.
Analysis by the Coroners Prevention Unit found a third of the deaths (55) occurred when the caregiver was using drugs or alcohol proximate to the infant’s death, and three-quarters (127) occurred while a baby was sharing a bed with an adult.
Coroner Jamieson found the baby’s “sleeping position was potentially hazardous” and that bed-sharing with babies carries inherent risks.
“These risks are exacerbated where the parent/s use alcohol and/or other drugs,” Judge Jamieson said.
Red Nose, the nation’s leading infant sleep safety authority, recommends infants sleep in their own space, such as a cot, on their backs with their face and head uncovered.
TIMELINE
June 9, 2020 – Mother of Baby B is 20 weeks pregnant with him when she is reported to child protection authorities for allegedly using drugs.
October 15, 2020 – Baby B is born.
Staff at the Royal Women’s Hospital flag concerns for his safety with Child Protection.
November 8, 2020 – Child Protection receive report Baby B’s mother verbally threatened his older sibling at a supermarket while possibly drug affected.
November 11, 2020 – Baby B is seen with a black eye, which his mother says was caused by accident by his older sibling. Hospital staff report her screaming and swearing at her children and neglecting their needs while visiting their stepfather who was injured after falling from an electricity pole while alcohol affected.
Child Protection undertake a risk assessment in consultation with Lakidjeka, the Victorian Aboriginal Child Care Agency, and find the children are not at significant risk in their mother’s care subject to her entering a protective agreement plan prohibiting the children from having contact with their stepfather pending a full assessment or being exposed to family violence or substance misuse.
November 20, 2020 – A report is made to Child Protection alleging Baby B and his sibling are being neglected, their mother lacks basic parenting skills and the home environment was messy and chaotic.
December 5, 2020 – Baby B is declared dead at 7.50am after being found unresponsive in bed where he was sleeping between his mother and stepfather. A Child Protection investigation into the family was already underway.
Autopsy
Methylamphetamine, tramadol, codeine, morphine, methadone, oxycodone, diazepam, 6-monoacetylmorphine and delta-9-tetrahydrocannabinol were identified in a post-mortem hair sample.
The boy also had lung petechiae and thymus petechiae, potentially indicating SIDS or overlay, also known as smothering.
No natural disease, congenital abnormality or injury was identified.
Cause of death: SIDS category 2
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