Child protection services failed Tasmanian baby found dead on mattress, coroner says
A two-month-old baby would not have died if Child Safety Services (CSS) had removed her from the care of her drug-affected parents, a Tasmanian coroner has found.
- A newborn was found dead on a mattress in a lounge room
- Concerns were raised about risks to the baby before her birth
- The coroner found she did not die of natural causes
Rhiannon Pitchford died in the early hours of November 19 in 2014 after co-sleeping with her mother Kylie Haywood, who was sedated on over-the-counter medication.
The baby and mother were asleep on a mattress in a smoky lounge room in Burnie, where three adults including her father Joshua Pitchford were high on morphine and methamphetamine.
Coroner Olivia McTaggart determined the baby, who was found at least partially face down, did not die of natural causes and instead had been exposed to several risk factors.
She said they included:
- The high levels of smoking within the house
- The level of sedation of Ms Haywood
- The level of drug intoxication of Mr Pitchford
- And the baby’s mild bronchiolitis
It is was unclear if the unsafe sleeping practices involved Ms Haywood rolling on top of Rhiannon.
Concern about the baby’s welfare was raised while her mother was pregnant, but CSS failed to follow up the notification when Rhiannon was born.
Ms McTaggart found if CSS had followed up the “unborn baby notification” and done a proper risk assessment at birth, “Rhiannon would not have been in the care of her parents at the time of her death” and ultimately would not have died that night.”
The coroner also said she was “satisfied that there was no deliberate act by Ms Haywood or Mr Pitchford done to cause Rhiannon’s death”.
Alert over sibling’s mistreatment
The coroner’s findings detail a litany of failures relating not only to Rhiannon, but the mistreatment of her siblings including a 20-month-old, referred to as W, who received non-accidental injuries.
Despite advice to the contrary, W was placed in the care of Ms Haywood and Mr Pitchford the day before Rhiannon died.
Ms McTaggart said the baby had been exposed to several risk factors that should have been acted on. (ABC News)
Coroner McTaggart said the injuries sustained by W, along with other factors, “disclosed a very high risk to a newborn infant”.
She said if Rhiannon had been removed from the home she would not have been exposed to three of the five factors found to have been risk factors in her death; bed sharing, being face down and smoking.
“In particular, her face would not have been pressed into adult bedding, restricting her respiration. In that case, I am satisfied that she would not have died,” she found.
“These failures in statutory function resulted in Rhiannon, once born, living in the home unprotected from the significant risks inherent in that situation and risks that were contributory factors in her death.”
CSS slow to protect siblings
The coroner also found the closure of Rhiannon’s CSS notification without a risk assessment was “erroneously” supported by a departmental panel set up to act as a robust check on such decisions.
“Even when concerns from a support worker about the extremely dirty state of the home were raised the day before Rhiannon’s death, CSS was not prompted to assess Rhiannon’s notification to take into account this serious risk factor,” she said.
Even after Rhiannon’s death, CSS was slow to protect the siblings known as L and B.
“Very surprisingly, arrangements for W’s reunification with Ms Haywood and Mr Pitchford continued for a period of time after Rhiannon’s death,” she said.
“The ongoing risk to L and B was not actioned until August 2015 when they were placed in care.”
The coroner also noted the difficulty in obtaining information from CSS necessary for the investigation into Rhiannon’s death.
The report makes five recommendations, including for the coroner to be notified if a child known to CSS under the age of three dies, and that information about known family members is also provided.
The report acknowledged reforms already underway as part of the redesign of CSS.
History of systemic failures
In June, Ms McTaggart found the death of 24-day-old baby Teegan Rose Hayes, who was accidentally suffocated in her parents’ bed in 2011, could have been prevented had child services acted appropriately.
Commissioner for Children and Young People Leanne McLean said she was saddened to read the coroner’s findings into Rhiannon’s death.
Ms McLean said she would be seeking a more detailed briefing from Children and Youth Services.
“There is a need now to learn from these mistakes, improve our collective efforts and improve responses to vulnerable children, especially babies and infants, to reduce the likelihood of such a tragic event occurring again,” Ms McLean said.
In a statement, Communities Tasmania said the department was already implementing changes to CSS in line with many of the coroner’s recommendations.
“These actions include placing a dedicated Child Safety Liaison Officer within the health system in the North and North West, broadening the parameters for what qualifies as an unborn baby alert, the commencement of a comprehensive training regime and the formation of a Serious Events Review Team.
“In addition to this, significant systemic improvements are being made through the Strong Families, Safe Kids reforms, which are designed to provide earlier intervention and better outcomes for at-risk children and their families.”
The Human Services Minister has been contacted for comment.