The death of an Aboriginal infant who died in Mparntwe / Alice Springs in 2024 was preventable, a coroner has found.
The 42-day-old girl died from Sudden Unexpected Death of an Infant (SUDI) just one week after she and her 21-year-old mother exited supported housing into "effective homelessness".
Coroner Elisabeth Armitage, who chose not to hold an inquest because the infant was not held in care or custody, noted that both the mother and child were staying in an overcrowded two-bedroom property with at least seven other people when the child died on September 22, 2024.
"That Mother would be homeless was not a secret. She was well known to various agencies," the coroner wrote. "However, no solution was found, and no safe sleep space for Infant was provided."
The 21-year-old, who had previously told a health service that "her father and stepmother were reported as not supportive, and her brother and his partner were 'aggressive and attack her,'" was sleeping with the infant on a single mattress on a lounge room floor.
"It was in this unsafe sleeping environment that Infant passed away just seven days later," Ms Armitage said.
The coroner noted that the mother loved and devotedly cared for the infant and that her death was an immense and life-altering tragedy for her family. She diligently attended antenatal care, gave birth at Alice Springs Hospital, attended postnatal care and was residing at premises designed to support new mothers. Furthermore, the infant was subjected to investigations by child protection.
"Despite those opportunities, there is very limited documented evidence of Mother receiving safe sleep education throughout her pregnancy and post-birth journey...she was exited into homelessness without that being addressed or the associated risks being mitigated," Ms Armitage said.
"This was a preventable death and more needed to be done to ensure safe sleeping was routinely discussed and promoted, that the risks of unsafe sleeping were clearly articulated, and that steps were taken to assist Mother to minimise or remove those risks to improve the safety of Infant, including by taking steps to ensure she and Infant had a safe place to sleep when exited from AAH [Ampe Akweke House]."
A post-mortem could not rule out "accidental asphyxia" as a cause of death, stating: "A co-sleeping arrangement is a well-established risk factor for SUDI, particularly when combined with substance use."
The mother had a history of cannabis use, which "could have influenced maternal sleep patterns and decision-making the night prior," the report added.
Ms Armitage was clear in her findings that "child removal is not an answer to homelessness".
"This 21-year-old single Mother was attentive, caring and protective of her Infant,' she wrote. "Addressing their joint homelessness and the risks that created for Infant was the necessary and called-for response."
1800 Respect (1800 737 732)
Lifeline (13 11 14)
13YARN (13 92 76)
Yarning Safe'N'Strong (1800 959 563)
Beyond Blue (1300 22 46 36)
