Coroner wants bassinets banned in childcare centres after baby’s death at ‘unsafe’ Sydney facility
A NSW coroner has recommended bassinets be banned in childcare centres after finding a series of failures contributed to the death of a seven-monthold baby at a Sydney facility.
Jack Loh was found unresponsive after being put to sleep in a bassinet in March 2019. It was just his fourth visit to the family childcare provider in Randwick.
After an inquest earlier this year, deputy state coroner Derek Lee on Wednesday found undiagnosed pulmonary hypertension caused Jack’s death on 4 March.
However, the condition was most likely exacerbated to a fatal level by the “unsafe” way in which he was put down for his nap that day.
Despite enough cots being available at the Rhythm and Rhyme Centre in Randwick, the infant was placed in the bassinet – considered unsafe for children aged four months and older and too small for him anyway.
It was almost 30C, but Jack was laid down fully clothed and loosely wrapped in a blanket, in a room with no fan, air conditioning or open windows. He was wearing a bib, which, along with a pillow in the bassinet, posed a suffocation risk.
The seven-month-old was left alone in the room without a baby monitor for about 40 minutes – three times the interval recommended for checks – as centre director Helen Rateau made “business and personal phone calls”.
All those circumstances likely decreased his ability to breathe properly, upping his stress and blood pressure, the coroner concluded.
Senior staff at Kidstart, the company responsible for overseeing the family-run centre, were aware of safety risks in the lead up to Jack’s death but did nothing, the coroner said.
Faten Trad, the supervisor in charge of compliance checks, was not thorough and misrepresented how long she spent examining each property, the coroner found.
Rateau gave evidence that on occasion Trad would leave her car running outside while she ducked in to sign the visitors’ log and say a quick hello before leaving again.
Although she failed to properly assess the property regularly, Trad knew Rateau had a bassinet at the centre, despite having no children in her care for whom it was suitable, the court heard.
Trad denied she knew the bassinet was being used and did not raise the issue with Rateau.
That was “a missed opportunity” to eliminate the risk before Jack had even enrolled at the centre, Lee said.
He found Rateau had already known the bassinet was unsuitable for the children she cared for – concluding she “most likely” hid it from prospective clients. Kidstart also knew Rateau was not operating within legal
staff-to-child ratios and that her CPR accreditation had lapsed.
Lee found neither issue had a material impact on Jack’s death but were indicative that the company, which has since been shut down, had been “prioritising profit over quality of care”.
He was scathing of director Aman Shamsin, who he deemed an “inherently unreliable” witness who was “evasive and non-responsive”.
“Ms Shamsin failed to take ownership of responsibilities which she bore as a director,” he said.
The Department of Education prosecuted Rateau, Trad and Kidstart for various offences under the national law, with all having pleaded or been found guilty.
But Lee was similarly critical of the department which was supposed to ensure the company was compliant with safety standards.
It had received several complaints about Kidstart that should have put it on notice that the company may have been operating inappropriately.
While no factor could singularly be identified as causing Jack’s death, all had culminated in the “heartbreaking” tragedy, the coroner said.
“The promise of years of life that Jack had to fulfil, which has now been taken away, is devastating,” Lee said.
Jack was so dearly loved for his “very developed soul”, bright blue eyes, and social personality, his parents told the inquest.
Lee recommended safe sleep training be made mandatory for family daycare educators and that they be required to undertake risk assessments on safe sleep practices and procedures.
He also recommended the law be amended to expressly prohibit the use of bassinets in early childhood education and care settings.