Coroner's Finding: ALSFORD Brayden John

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 4th and 20th days of October, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Brayden John Alsford.

I, the said Coroner, do find that Brayden John Alsford, aged 15 months, late of 7 Hobart Crescent, Salisbury Heights, died at 7 Hobart Crescent, Salisbury Heights on the 6th day of November, 1999 as a result of neck compression from hanging. I find that the circumstances of death were as follows:-

1. Introduction 1.1 Brayden Alsford was put to bed by his mother at about 11.30a.m. on Saturday 6 November 1999. He slept in a wooden cot.

1.2 Brayden’s mother, Mrs. Michelle Alsford, said in her statement that she closed the curtains on the northern side of the cot using the curtain rope which was directly next to the cot. She said: “Upon completing this I let the curtain rope go as it usually falls back behind the curtain due to the weight of the rubber. I thought that it had done this on this occasion. The curtain rope was definitely not inside the parameters of the cot’s internals”. (Exhibit C1a, p2).

1.3 Mrs. Alsford went in to check Brayden about ten minutes later. When she did so, she found that the curtain cord was around Brayden’s neck, and his face was blue.

1.4 Mrs. Alsford took Brayden to a neighbour’s house, and he tried to resuscitate him, while talking on the telephone to ambulance officers. When the ambulance arrived, the officers made further attempts to revive him, but he remained without a pulse or respiration (Exhibit C.5a, p1).

1.5 Brayden was taken to the Lyell McEwin Hospital by ambulance, but he was dead on arrival. Dr. Jane Rowland formally pronounced life extinct at 12.30p.m. on 6 November 1999.

1.6 When Constable AT Schroeder of Salisbury Patrols attended to investigate the death, he found the curtain cord hanging inside the cot (Exhibit C6a, p1). Senior Constable Carpenter of Elizabeth Investigation Section also attended at the house and noted the position of the cord. The scene was measured and photographed. Senior Constable Carpenter concluded: “After examining the scene, and assessing all information available to me at this time, and although the circumstances of death are unusual, I am satisfied that there is nothing suspicious surrounding the death of Brayden Alsford. It appears that the death was caused by strangulation by the curtain cord”. (Exhibit C.7a, p2).

2. Cause of death 2.1 A post mortem examination was performed by Associate Professor R.W. Byard, Forensic Pathologist, on 7 November 1999. Dr. Byard confirmed that the cause of death was “neck compression due to hanging” (Exhibit C.9, p1). He added:- “Hanging from a curtain cord is a well-recognised risk to toddlers of Brayden’s age”.

(Exhibit C.9, p2).

2.2 Dr Byard found that Brayden was an otherwise healthy, well-developed little boy.

There was no significant underlying organic disease which could have caused or contributed to the death. A toxicological examination also proved negative (see Exhibit C3a).

2.3 Dr. Byard is an internationally recognised authority on the phenomenon of sudden unexpected infant death, and has been involved in the “Safe Sleeping Campaign”, involving State Forensic Science, Kidsafe and the Womens and Childrens Hospital, for a number of years.

2.4 Dr. Byard explained the mechanism of death in these cases as follows:- “With infants sometimes you only need pressure on one side of the neck to cause death.

Death occurs by a number of mechanisms, one of them is stopping the venous blood coming back from the brain to the heart and you get a problem then getting oxygen out of the blood to the brain, you can also block off the arteries taking blood to the brain themselves, you can block off airways sometimes less commonly and the other possibility is that you can stimulate nerves in the neck which can then stop the heart, the

heart slows and then it stops and probably in cases like this it is a combination of all of those factors and it can occur very quickly, in a matter of seconds”. (T.7).

2.5 Dr. Byard gave the following advice for parents of young children:- “The basic message is all sorts of cords and ropes are dangerous for toddlers, because they will wrap them around their neck, they don’t appreciate the dangers, they can’t - often they don’t have the manual dexterity to get the cord away from their necks or they don’t have the strength sometimes. So specifically with curtain cords, curtain cords should be kept out of reach of toddlers, which means either looping the cord up over the curtain rod or getting a device that Kidsafe has, it’s a ... device that a curtain cord can be put into that actually retracts the cord. The other point is that if a baby is in a cot in a room and there is a curtain cord near the window, don’t put the cot near the curtain cord, just keep the curtain cord out of reach. But it’s not only curtain cords, it’s also mobiles that have string, dummies that have long strings, any piece of cord that’s long enough to go around a toddler’s or baby’s neck can be dangerous”. (T.9).

3. Finding 3.1 I accept Dr. Byard’s evidence and rely upon his experience and expertise in the area.

I find that Brayden Alsford died as a result of having become accidentally suspended around the neck as a result of becoming entangled in a curtain cord.

3.2 I believe that the circumstances of this case call for a public warning to be given to the parents of young children about the risks involved in allowing such children to have access to ropes or cords which are long enough to go around the child’s neck. Parents should ensure that curtain cords are kept out of the reach of small children. It is recommended that the brochure made available by Kidsafe as part of the Safe Sleeping Campaign should be consulted, as this offers advice and assistance to parents about how to avoid such risks.

Key Words: hanging; infant death; public warning In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 20th day of October, 2000.

……………………………..……… Coroner Inq.No.42/2000