THE CORONER examining the death of an infant here two years ago has ruled it as undetermined and made no recommendations.
The eight-month-old boy died at about 3 a.m. July 28, 2010 and the coroner’s report noted that “an unsafe sleep environment is a contributing factor.”
On July 28, 2010, Terrace RCMP and paramedics were called out for a report of an unresponsive infant. “Upon arrival, police and paramedics entered the residence and discovered an eight-month-old infant who was deceased on scene. The cause of death at this point is unknown,” reported police at that time.
The boy was born by caesarean section and was the second of twin boys, having a low birth weight of 2,290 grams (5.05 lbs.), said the coroner’s report.
He was discharged from hospital five days after birth and weighed 2,355 grams (5.19 lbs.) at that time, continued the report.
“The public health nurse and family physician both discussed safe sleep arrangements with [his] family,” said the report. “There was a crib available for [him] to sleep in however he frequently slept in an adult bed with his family members.”
The coroner’s report said that shortly after midnight July 28, 2010. the infant was placed on his back on an adult double bed, wearing a diaper and not covered by any sheets or blankets, said the report.
A family member last checked on him at 2:30 a.m. and then fell asleep on the bed beside him, the report continued. He was laying on his back with his head toward the head of the bed, between the family member and the wall, said the report.
Sometime during the night, the family member grew cold and pulled up a blanket to cover them both, continued the report.
“The family member awoke just before 0700 hours and threw back the covers that had been completely covering [the child]. He was discovered to be lying on his back with his feet toward the wall...It was noticed right away that [he] was not breathing or moving. [He] was moved quickly to the living room and CPR was attempted by a family member while 911 was called,” continued the report.
“The BC Ambulance Service arrived at 0702 hours and attempted to ventilate [him],” which was unsuccessful, said the report.
Cause of death of an infant is determined by examining the scene, obtaining medical history and doing postmortem exams, which includes ruling out disease, said the report.
“Risk factors may be identified that cannot be excluded as it relates to the death. The role of an external condition or risk factor may not be fully known or can be difficult to evaluate, prove or disprove and therefore cannot be excluded.
“In this case, the role of an unsafe sleep environment may be considered a risk factor as it related to the death,” said the report.
No cause of death could be determined and a number of injuries that were healing weren’t serious enough to cause death, said the report.
“Death by an asphyxial mechanism cannot be ruled out as it is a diagnosis of exclusion with very few findings at autopsy,” said the report.
Coroner Adele Lambert, who wrote the report, said “asphyxial mechanism” is suffocation due to a blocked airway, which could happen in a variety of ways; however, she stressed that although it may be a part of what happened to the boy, it does not mean that is what caused his death.
“Often times when an autopsy is done, they don’t necessarily find a cause of death,” said Lambert.
As for why no recommendations were made to prevent the death of another child, Lambert said not every report has recommendations and the coroner can’t address recommendations to individuals – they must be made to a wider audience.
In regards to putting a baby to sleep safely, it’s up to the parents to decide whether to follow the suggested guidelines, she said.
Lambert said that the Ministry of Children and Family Development received a copy of her report as did the Representative for Children and Youth Mary Ellen Turpel Lafond.
The Office of the Representative for Children and Youth has yet to make an official statement on the coroner’s report.
“...the Representative can only launch an investigation or review once all pending criminal investigations and any coroners’ reviews have been completed,” said Carla Wormald from the representative’s office.
“Only once a formal investigation is launched would we publicly comment on any specific cases,” she said.
The Representative for Children and Youth helps children, youth and families who need assistance in dealing with the child-serving system, provides oversight to the Ministry of Children and Family Development and advocates for improvements to the child-serving system.
The position is not part of the government and doesn’t report through a provincial ministry – the representative is an independent officer of the legislature.
Police are not investigating the child’s death.
“The file is concluded,” said Terrace RCMP spokesperson Const. Angela Rabut.