A coroner in the Australian state of New South Wales (NSW) has recommended a suite of reforms after finding a series of failures contributed to the death of a seven-month-old baby at a Sydney daycare centre.
It was only Jack Loh’s fourth visit to the family childcare provider in Randwick when he was found unresponsive after being put to sleep in a bassinet on March 4, 2019.
Delivering his findings after a two-week inquest earlier this year, deputy state coroner Derek Lee found undiagnosed pulmonary hypertension caused the boy’s death.
However, Magistrate Lee said the blood pressure condition was most likely exacerbated to a fatal level by the unsafe way in which Jack was put down for his nap that day.
The boy was loosely wrapped in a bassinet, which was too small for him, instead of the cot recommended for children of his age.
Bassinets are generally not recommended for babies at all, but are considered unsafe for those aged four months and older who can roll from front to back.
Jack was also put to sleep fully clothed in a room which was poorly ventilated and not temperature appropriate.
He was wearing a bib, which, along with an extra loose sheet and pillow in the bassinet, posed a suffocation risk.
He was left alone and unchecked for two-to-three times as long as recommended, as the woman looking after him made “business and personal phone calls.”
All those circumstances likely increased the boy’s stress and blood pressure to the point it killed him, the coroner concluded.
Not only was the centre unsafe, but the care provider had let her CPR accreditation lapse, although Magistrate Lee found this had no material impact on Jack’s death.
While Magistrate Lee found no fault with medical professionals who failed to diagnose Jack with the condition, he was scathing of the Department of Education and the childcare company which were supposed to ensure the daycare was compliant with safety standards.
He deemed the director of Kidstart, the company responsible for the centre, to be an “inherently unreliable” witness who was “evasive and unresponsive.”
“She failed to take ownership of responsibilities which she bore as a director,” he said.
“Instead, [she] repeatedly sought to deflect these responsibilities onto others.”
The company, which has since been shut down, had been “prioritising profit over quality of care,” he said.
The Department of Education had received a number of complaints—both about Jack’s daycare centre and about Kidstart in general—that there were “widespread safety concerns” in relation to educators engaged by the company.
Magistrate Lee recommended the national law be amended so that family daycare educators are required to undertake mandatory safe sleep training, and that they be required to undertake risk assessments on safe sleep practices and procedures.
He also recommended national law be amended to expressly prohibit the use of bassinets in early childhood education and care settings.
