Demographics
unknown
Coroner
Coroner King
Date of death
2012-04-13
Finding date
2014-10-27
Cause of death
unascertained
AI-generated summary
An 8-week-old infant in out-of-home care died suddenly while asleep in a porta cot. Post-mortem examination revealed no infectious disease, injury, or toxicological abnormality. The cause remained unascertained despite extensive investigation including virological, microbiological, and radiological testing. The coroner found the sleeping environment and care provided were reasonable and appropriate, excluding unsafe sleep practices as contributory factors. This case highlights sudden unexplained infant death and the limits of forensic investigation. While no preventable factors were identified, the case underscores the importance of continued research into sudden infant deaths and the need for comprehensive assessment of sleeping environments and care practices in all infant deaths.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Coroners Act 1996 [Section 26(1)] Western Australia
RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref: 38/14 I, Barry Paul King, Coroner, having investigated the death of Baby Xavier with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth, on 17 October 2014, find that the identity of the deceased person was Baby Xavier and that death occurred on 13 April 2012 at Amblin Caravan Park, Broadwater, from an unascertained cause in the following circumstances: Counsel Appearing: Ms C Fitzgerald assisting the Coroner Mr L Villiers (State Solicitors Office) appearing for the Department of Child Protection
SSUUPPPPRREESSSSIIOONN OORRDDEERR The name and identity of each of the deceased and the deceased’s mother not be published.
Inquest into the death of Baby Xavier 4045/2012
TTaabbllee ooff CCoonntteennttss
Baby Xavier (the deceased) died suddenly on 13 April 2012 while lying in a porta cot. He was eight weeks old.
As the deceased was a person in the care of the CEO as defined in section 3 of the Children and Community Services Act 2004 at the time of his death, he was a ‘person held in care’ under section 3 of the Coroners Act 1996.
Section 22 (1)(a) of the Coroners Act 1996 provides that a coroner who has jurisdiction to investigate a death must hold an inquest if the death appears to be a Western Australian death and the deceased was immediately before death a person held in care.
An inquest to inquire into the death of the deceased was therefore mandatory. Accordingly, I held an inquest on 17 October 2014 in the Perth Coroners Court.
Inquest into the death of Baby Xavier 4045/2012
The deceased was born in Rockingham General Hospital on 18 February 2012 by normal vaginal delivery. He was 3050 grams at birth. He established spontaneous breathing around one minute after delivery.1
Due to mental health issues after she had given birth to the deceased, the deceased’s mother was unable to feed or care for him properly. As a result, a hospital social worker contacted the Department for Child Protection (the department).2
On 22 February 2012 the department took the deceased into its care under a provisional protection and care order and placed him with a foster carer, Pamela Goodlich, the next day.3 On 22 March 2012 the Perth Children’s Court made an interim order that the deceased remain in provisional protection and care pending DNA testing of the deceased’s putative father.4
On 14 March 2012 Ms Goodlich took the deceased to Rockingham General hospital for a follow-up appointment with a consultant paediatrician, Dr Mohammad Jehangir. Ms Goodlich had noticed that the deceased had started to become unsettled after his feeds.5
Dr Jehangir examined the deceased and diagnosed him with gastro-oesophageal reflux and possibly cow’s milk intolerance. Apart from that, the deceased looked well and his physical examination was normal. Dr Jehangir prescribed five milligrams of omeprazole daily and 1 Exhibit 1, Tab 14 2 Exhibit 1, Tab 8 3 Exhibit 1, Tab 8 4 Exhibit 2, Tab 3 5 Exhibit 1, Tab 14 Inquest into the death of Baby Xavier 4045/2012
Neocate milk. He arranged for a review in six to eight weeks.6
Ms Goodlich lived in Rockingham. She was a full-time carer for the department. She had a nursing background which allowed her to care for children with medical needs. Prior to caring for the deceased, she had provided 47 placements, many of whom were infants and children.7
Department staff noted that Ms Goodlich provided a high standard of care of children. Executive Director Metropolitan Services of the department, Cheryl Barnett, provided oral evidence in which she confirmed her written evidence to the effect that, at the time of the inquest, Ms Goodlich continued to be regarded as a carer who provided high quality care of children, including children with high needs.8
At the time that the deceased was in her care, Ms Goodlich was also caring for her adopted four year and 11 month old daughter and a three and a half year old male foster child.9
On 1 March 2012 department staff undertook a placement check on Ms Goodlich’s home. Ms Goodlich advised that the deceased had settled in well and had slept for seven hours the previous night.10
Ms Goodlich had an on-site caravan at Amblin Holiday Park in Broadwater near Busselton where she had been spending every Easter school holidays for the previous 13 years. Two of her friends, Christine Lewis and Geraldine Atkinson would also stay there with their 6 Exhibit 1, Tab 14 7 Exhibit 1, Tab 8 8 ts 9 Exhibit 1, Tab 11 10 Exhibit 1, Tab 8 Inquest into the death of Baby Xavier 4045/2012
respective children and the three women would spend time together.
It seems that Ms Goodlich smoked tobacco, but it is unlikely on the evidence that she smoked indoors in the presence of the deceased. For example, her answers given to questions posed by investigators indicated that no persons smoked ‘in the home’, which I take to mean both her home and the caravan.11
Ms Barnett also provided evidence which satisfies me that the deceased provided Ms Goodlich with on-going instruction and up-to-date information relevant to the proper care of infants, including instructions not to smoke around children in her care and instructions relating to safe sleep environments for babies.12
I note in passing that a statement obtained from the deceased’s mother indicated that she did not take any medication during her pregnancy apart from omeprazole for reflux, which had been prescribed for her. She described the pregnancy as ‘hassle free’.13 Medical records from Rockingham General Hospital for the deceased’s mother indicate that she was not a smoker and had not smoked cigarettes during the pregnancy.14
On 5 April 2012 Ms Goodlich took the children in her care, including the deceased, to stay at her caravan in Broadwater.15
Every night the deceased slept in a porta cot with a bassinet insert. He always slept on his right side and he was normally a good sleeper.16 11 Exhibit 1, Tab 23 12 Exhibit 1, Tab 8; ts 21-22 13 Exhibit 1, Tab 13 14 Exhibit 2, Tab 2 15 Exhibit 1, Tab 9 16 Exhibit 1, Tab 9 Inquest into the death of Baby Xavier 4045/2012
On 13 April 2012 Ms Goodlich and the children in her care went shopping and went to the park. The other children had a swim in the pool at the caravan park while the deceased slept outdoors.17
Around 3.00 pm Ms Goodlich’s friend Ms Atkinson arrived at the caravan park with her two children.18
At about 4.30 Ms Goodlich gave the deceased his prescription of omeprazole and a bottle of Neocate formula.19
At about 5.00 pm Ms Lewis arrived with her son. Both Ms Atkinson and Ms Lewis nursed the deceased, who was smiling and apparently healthy.20
About 7.15 pm the friends and their children had dinner. The deceased had more Neocate and then went to sleep in the porta cot in Ms Goodlich’s bedroom in the caravan.21 He was wearing a singlet and jumpsuit and had a thin blanket up to his armpits. He was lying on his right side.22
The other two children in Ms Goodlich’s care fell asleep in the living area of the caravan while Ms Goodlich socialised with her friends on the veranda. Ms Goodlich regularly checked on the children during the evening.23 At 8.30 pm she noted that the deceased was lying on his right side and breathing normally.24
At about 10.00 pm Ms Goodlich’s friends left her caravan to return to their own caravans for the night.
Ms Goodlich went inside to the porta cot where the deceased was sleeping and saw that he appeared pale 17 Exhibit 1, Tab 9 18 Exhibit 1, Tab 10 19 Exhibit 1, Tab 9 20 Exhibit 1, Tab 11 21 Exhibit 1, Tab 11 22 Exhibit 1, Tab 9 23 Exhibit 1, Tab 11 24 Exhibit 1, Tab 9 Inquest into the death of Baby Xavier 4045/2012
and was not breathing. 25 She ran out to Ms Lewis’ caravan, screaming for help.26
She sent her son to get Ms Atkinson and called ‘000’.27
At 10.55 pm his life was certified by a doctor to be extinct.30
Dr D M Moss found no evidence of injury or natural disease to account for death.32
to be non-specific, and the microscopic examination was also unremarkable. Dr Moss elicited the assistance of Dr Adrian Charles, a consultant paediatric and perinatal pathologist at Princess Margaret Hospital, who confirmed his findings.
Post mortem x-rays were reviewed by Dr Fiona Bettenay, a consultant radiologist at Princess Margaret Hospital, who confirmed that the skeleton was normal apart from possible fractures from resuscitation attempts and that the deceased’s development appeared normal for his age.
Neuropathological examination of the brain showed non-specific cerebral congestion macroscopically.
Microscopically the brain was normal.
He said that most of our infant deaths end up as unascertained.33
Dr Moss concluded that in his opinion the cause of death was best given as ‘unascertained’34, which I adopt.
As to the issue of how death occurred, in his post mortem report Dr Moss commented that the deceased’s 33 ts 14 34 Exhibit 1, Tab 5 Inquest into the death of Baby Xavier 4045/2012
bed as it was described in the P98 Mortuary Admission Form was not a particularly unsafe sleeping environment.35
Dr Moss was also asked about this issue in oral evidence; in particular he was asked to comment on the evidence that the deceased was lying on his side on a folded quilt with a light blanket up to his armpits.36 He said it is difficult to interpret the evidence in this case without knowing exactly what the circumstances were, but that (in general) it would be highly unlikely that he would see any evidence of asphyxia on a post mortem examination in any case.37 He said that if the deceased was on his back, his bedding was probably irrelevant, and that if the deceased was on his side or front with a soft blanket, it would have been a slightly less safe sleeping environment.38
Dr Moss noted that placing babies on their backs to sleep is accepted to be the safest position, but that the benefit of that practice is identified in contrast to placing babies on their stomachs.39 He said that placing a baby on his or her side might have advantages where the baby suffered from gastro-oesophageal reflux.40 He said that a baby of the deceased’s age would not be expected to roll onto his stomach from his back.41
Because the cot and the bedding were packed up before police investigators could examine it, it could not be examined to determine whether it could have caused or contributed to the death. However, the statements of Ms Lewis and Ms Atkinson both establish that the deceased was on his back when they went to him after being called by Ms Goodlich.42 Ms Goodlich’s statement 35 Exhibit 1, Tab 5 36 ts 13 37 ts 13, 16 38 ts 13 39 ts 13, 16 40 ts 18 41 ts 13 42 Exhibit 1, Tab 10, Tab 11 Inquest into the death of Baby Xavier 4045/2012
established that the deceased was on his side throughout the evening.43
The deceased died suddenly and without ascertainable cause at eight weeks of age while apparently healthy and in the care of an experienced and responsible foster mother. Unlike many other deaths of infants while sleeping, co-sleeping and other unsafe sleeping environment factors can be excluded as likely contributors to his death.
The tragedy of Baby Xavier’s death provides a solemn reminder of the fragility of life and of the need for the continued research into sudden and unexplained deaths of infants.
Barry King Coroner 27 October 2014 43 Exhibit 1, Tab 10 Inquest into the death of Baby Xavier 4045/2012
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