A coronial investigation into the death of an eight-week-old boy has revealed how Queensland's Child Safety Department ignored crucial warning signs from medical experts before the infant died in his mother's lap.
The child — known as T — was born at Logan Hospital, south of Brisbane, in June 2015 with methadone and amphetamine in his body.
He was found dead less than two months later with his sleeping mother slumped over his body on the couch.
A forensic pathologist determined T had died of Sudden Infant Death Syndrome (SIDS) and that it was highly likely mechanical asphyxia had occurred.
The family was known to the Child Safety Department due to the mother's history of drug abuse, which had resulted in two of her older children being removed from her care.
After T's birth, nursing staff reported seeing blankets over his face while the parents were present and said the mother had been found asleep on top of him while he was lying in a large cot.
The mother denied she used drugs during her pregnancy, but a test later found her positive for methadone, amphetamine and methamphetamine.
A family risk evaluation completed less than three weeks after T's birth deemed the circumstances "high risk", but a safety assessment found the baby was "safe" in the family home.
An investigation by Deputy State Coroner Jane Bentley found the Department ignored important information provided by medical professionals about the risk her drug used posed to the baby's safety.
"I find that the department's assessment of T as being a child not in need of protection was incorrect," Ms Bentley said.
"Doctors and nurses warned the department that the mother was using drugs and had fallen asleep on top of T but the department did not adequately assess that information.
"I publish these findings in order to highlight the risk factors for SIDS including co-sleeping and the use of drugs."
The death was investigated by the Child Death Case Review Panel (CDCRP), which said it was "alarmed at the poor and completely inadequate response by the department to the very serious child protection issues" in T's case.
The panel found there was "clear evidence that the mother was using amphetamines" but it was accepted that she would "work with the department voluntarily to ensure T could remain with her at home".
The panel said if department staff did not change their unsafe practices, their work may result in "children being placed at an unacceptable risk of future harm".
.png?w=600)
