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The coroner has found the young whānau of a 10-week-old baby who died while co-sleeping were not given adequate support.
The baby girl's mother woke to find her daughter unresponsive in bed next to her at their home in August 2019. Emergency services were called but the baby could not be resuscitated.
A post-mortem found the baby was in the early stages of pneumonia and with some inflammation of the upper airways, but this was not what caused her death.
Concerns had been raised by several health practitioners with Oranga Tamariki about the mother's health before the child's death.
Coroner Sue Johnson found the mother had a history of self-harm and mental health issues, and had attempted suicide after her daughter's birth.
She then spent time in a mental health inpatient unit and her midwife sent a referral to Oranga Tamariki detailing her concerns.
"Self-discharged from hospital with a pre-term baby. Declined all offers of support ... this is an at-risk baby living with a young mother with MH [mental health] and drug issues."
The family moved to a different city after the mother was transferred to a mothers and babies inpatient service, to provide her with parenting support so her mental health could be assessed.
The family were educated on the risks of co-sleeping and were given a pēpi pod for the baby to sleep in while on the bed with her parents.
Despite this, the baby was found in her mother's bed on at least six occasions and moved by staff into the pēpi pod.
Staff remained concerned about the mother, who used a razor to cut herself, left her baby unsupervised in the bath, used alcohol and cannabis, refused her medication, lacked engagement, and was mechanical in her interactions with her daughter.
In the months before the child's death, a psychiatrist told Oranga Tamariki that the parents were determined and willing to make changes to provide their daughter with safe, consistent care but that they would need support to ensure their baby was safe and received responsive care.
A GP who administered the child's six-week immunisations noted she was clean, well fed and there were no signs of injury, but she had concerns about the mother and the lack of support.
Further contact was made with Oranga Tamariki to ensure the baby's care had been transferred to the city to which the family had moved. The case was slow to be transferred between offices, and an agreed safety plan was not being followed.
Johnson said the ministry did not ensure the baby or her whānau had the right level of support in place and her safety was never properly assessed.
The GP who the mother and baby had visited weeks earlier, expressed concerns to the coroner about their experience with Oranga Tamariki, saying there was a "significant system failure" which led to the baby's death.
The lack of a discharge summary on the baby's clinical record from her time in the mothers and babies inpatient service meant that it was not clear whether a safety network had been established for the mother and the baby.
Since the baby's death, Oranga Tamariki has strengthened its case transfer process and updated its guidance to those working with parents on how to improve safe sleeping environments for babies, among other changes.
Johnson said once implemented, the changes would go some way to preventing further deaths in similar circumstances.
She said the death was a tragic reminder of the danger to babies that are placed in a co-sleeping environment.
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
Lifeline: 0800 543 354 or text HELP to 4357
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz
What's Up: free counselling for 5 to 19 years old, online chat 11am-10.30pm 7days/week or free phone 0800 WHATSUP / 0800 9428 787 11am-11pm Asian Family Services: 0800 862 342 Monday to Friday 9am to 8pm or text 832 Monday to Friday 9am - 5pm. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi and English.
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
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OUTLine: 0800 688 5463 (6pm-9pm)
If it is an emergency and you feel like you or someone else is at risk, call 111.
