Finding into death of Livinia Rose Kenna

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2016 1714

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PETER WHITE, Coroner having investigated the death of LIVINIA ROSE KENNA.

without holding an inquest:

find that the identity of the deceased was LIVINIA ROSE KENNA

born on 28 March 2016

and the death occurred between 15 April and 16 April 2016

at 49 Moffat Crescent, Hoppers Crossing, Victoria

from: 1 (a) SUDDEN INFANT DEATH SYNDROME (SIDS CATEGORY ID

Pursuant to section 67(1) of the Coroners Act 2008, there is a public interest to be served in making findings with respect to the following circumstances:

1. Livinia Rose Kenna was 19 days old at the time of her death. She resided with her parents, Michael and Bronwyn Kenna, and her older sisters, Elle and Sienna.

2. Bronwyn’s obstetrician, Dr Anthony Woodward reported no concerns or complications either during Bronwyn’s pregnancy, or after Livinia’s birth!.

3. Bronwyn was taking Pristiq’, whilst pregnant with Livinia, and after Livinia’s birth. Dr Woodward was not concerned by this’.

4, Other than experiencing episodes of painful wind, Livinia was in good health.

' Coronial Brief of Evidence (Statement of Dr Anthony Woodward).

? Pristiq is a drug used for the treatment of major depressive disorder. Pristiq is the drug’s trade name; its generic name is desmethylvenlafaxine.

Coronial Brief of Evidence (Statement of Dr Anthony Woodward).

On 5 April 2016, a Maternal Child and Health Care Nurse from Mossfield Maternal Child Health Centre attended Michael and Bronwyn’s residence to complete a home visit. A Safe Sleeping Checklist* (“the checklist”) was undertaken. Documentation provided by Mossfiel Maternal and Child Health Centre indicate that the Child Health Care Nurse discussed SIDS® regulation and recommendations about Livinia’s sleeping arrangements with Bronwyn, however, did not see the couple’s cot arrangement for Livinia.

Livinia’s bassinet was branded a Charlotte Bassinet. It was purchased by Michael and Bronwyn from a department store around the time of Elle’s birth and was used by both Elle and Sienna when they were babies. The bassinet came with a cover/bassinet liner that covered both the inner and outer side of the bassinet and a bassinet canopy; all of which were on the bassinet. The inner side of the bassinet was covered thinly with a quilt-like material. The bassinet also had a thin wooden base. On top of the base was a thin mattress with a plastic cover that was made for the bassinet which could not be removed. In addition to this, a second mattress had been placed on top of the bassinet mattress. This mattress was from a pram and fit snuggly at the base of the bassinet, however, not at the top of the bassinet; leaving a gap of approximately seven centimetres on the side of the bassinet. On top of this mattress was a woollen underlay, which did not fully reach to the sides of the bassinet.

On 12 April 2016, Bronwyn took Livinia for a check-up to her maternal child health appointment at Mossfield Maternal Health Centre, Hoppers Crossing. The Maternal Child and Health Care Nurse noted that Livinia had not lost any weight, however, had not gained any weight either. As a consequence, Bronwyn was advised to begin mix feeding Livinia with breast and bottle milk.

On 15 April 2016, at approximately 3:30pm, Michael returned home from work. A short time later the entire family went to the supermarket to purchase groceries for dinner that night. This was the first time in weeks that the family were without visitors.

At approximately 6:00pm, after spending some time outside watching Elle and Sienna playing, Michael and Bronwyn had dinner. They both consumed alcohol during, and after the meal; Michael had a few beers, whilst Bronwyn consumed approximately three to four glasses of wine; with the exception of a glass at her sister-in-law’s wedding, it was the first time Bronwyn had consumed any alcohol in approximately 12 months.

At some stage between 8:00pm and 8:30pm, Michael bathed Livinia, whilst Bronwyn tucked Elle and Sienna in bed. They then sat down to watch the football together. Whilst doing so, the couple took turns nursing Livinia in an effort to settle her.

4 The Safe Sleeping Checklist was an initiative developed by the Victorian State Government in partnership with SIDS and Kids. The purpose of the checklist is to help parents take simple measures to ensure that their baby sleeps safely.

Following childbirth, families receive education on safe sleeping methods for their baby by a maternal and child health nurse when they conduct their first home visit. The education focuses on the sleeping safety of babies during their first year to reduce the risk of SIDS. The Safe Sleeping Checklist comprises of a total of ten categories, whereby the Maternal Child and Health Care Nurse needs to identify whether each category is either a ‘close match to statement’, ‘does not match’, or is ‘not applicable’.

5 SIDS is the abbreviation for Sudden Infant Death Syndrome. It is also known as cot death or crib death.

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11. At approximately 10:30pm, Livinia fell asleep on Bronwyn’s chest. A short time later, Bronwyn took Livinia to bed. She placed her in the bassinet, laying Livinia on her stomach, about halfway down the bassinet. Bronwyn described Livinia’s head as being at the bassinet’s halfway mark and facing left, whilst her feet were approximately a quarter of the way up from the bottom of the bassinet. Bronwyn had tucked Livinia in by placing a wrap over her, folding the tip over Livinia’s shoulder and tucking the bottom of the wrap underneath the mattress at either side and at the bottom tightly. The wrap was at the base of Livinia’s neck, near her shoulders. Bronwyn then placed another wrap on the top of this one. She then placed a pink cotton blanket on top of the wrap and then another embroidered baby blanket on top of the pink cotton blanket. All blankets were tightly tucked in, with Livinia sleeping with her hands at the side, up near her face. In the top right hand side corner of Livinia’s bassinet, was a dummy and a material bunny rattle.

12. Livinia was dressed in a singlet, disposable nappy, and a jumpsuit. The central ducted floor heating was set to 22 degrees. According to Bronwyn, the bedrooms always reached a higher temperature than the hallway, and as such, a thermostat was placed in Livinia’s room to ensure that her room temperature did not exceed, or drop below 22 degrees.

13. On 16 April 2016, at approximately 6:40am, Bronwyn awoke observing that daylight was coming through her window. She became panicked with the realisation that she had not been roused by Livinia during the night. She jumped out of bed and ran downstairs to Livinia’s bedroom.

14. Upon approaching Livinia’s bassinet, Bronwyn observed that Livinia had moved up in the bassinet; towards the left hand corner. She was still face down on her stomach, however, was now out of the blankets. Livinia’s head and body were angled, and fully wedged at the top left hand corner of the bassinet, between its side and the mattress. Her skin was blue, and she was unresponsive. Bronwyn picked Livinia up and called out to Michael.

15. Upon reaching Bronwyn, Michael took Livinia off her. He immediately called ‘000’.

Michael advised the operator that Livinia was not breathing. He commenced cardiopulmonary resuscitation (“CPR”), under the operator’s instruction.

16. At approximately 6:42am, Ambulance Victoria paramedics (“the paramedics”) arrived and examined Livinia. They continued with CPR.

17. A short time later, Michael and Bronwyn were advised by the paramedics that Livinia had passed away.

18. Forensic Pathologist, Dr Matthew Lynch of the Victorian Institute of Forensic Medicine, performed a post mortem autopsy. Dr Lynch provided me with a report of his findings.

Upon completion of the post mortem autopsy examination Dr Lynch formulated that Livinia died from Sudden Infant Death Syndrome (SIDS Category I).

19. SIDS is defined as “the sudden, unexpected death of an infant less than one year of age with the onset of the fatal episode apparently occurring during sleep that remains unexplained

after a thorough investigation including performance of a complete autopsy and review of the circumstances of death and the clinical history”®.

20. Post mortem toxicology studies were also performed. Testing revealed the presence of desmethylvenlafaxine. It was noted that Bronwyn had been prescribed this drug and had taken it both during the pregnancy and after Livinia’s birth. Dr Lynch stated that Livinia most likely ingested the drug via breast milk.

21. As part of my investigation, Detective Senior Constable Laura Kilpatrick provided me with a coronial brief of evidence (“the brief’). The brief contains statements from Livinia’s parents, Bronwyn’s obstetrician, and Detective Senior Constable Kilpatrick.

22. On the evidence before me, I am satisfied that Livinia Rose Kenna died from Sudden Infant Death Syndrome (SIDS Category II) at the age of 19 days.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1. In light of a home visit being conducted by a Maternal Child and Health Care Nurse from the Mossfield Maternal Health Centre; I suggest that all Maternal Child and Health Care Nurses are counselled not only to provide oral advice to families of babies, but to also thoroughly review the environment in which the baby is living.

I direct that a copy of this finding be provided to the following: Mr Michael Kenna and Mrs Bronwyn Kenna, Senior Next of Kin

Detective Senior Constable Laura Kilpatrick, Coroner’s Investigator

Mossfield Maternal Child Health Centre

Signature: P A : OO 7 ¢ | ae PETER WHITE «i

CORONER Date: 21 February 2017 c

6 Krous HF, Beckwith JB et al. Sudden Infant Death Syndrome and Unclassified Sudden Infant Deaths: A Definitional and Diagnostic Approach. Pediatrics 2004; 114; 234-238.