The coroner released her findings without holding an inquest into the death of the infant, who died from sudden unexpected death of an infant (SUDI) in September 2024. The condition is distinct from sudden infant death syndrome (SIDS), which is only diagnosed when a death cannot be explained by a baby's sleeping environment.
Coroner Armitage said the 21-year-old mother, who is not named, was "known to be a good mother who was attentive to her infant's needs." Despite being "well known to various agencies," she was evicted from her accommodation "into effective homelessness" and "no safe sleep space for [the] infant was provided," meaning they were forced to sleep together on a single mattress on a relative's lounge room floor.
The mother fell pregnant in January 2024 and was assaulted by her brother and sister-in-law, during which she was "pushed to the ground, punched in the face and her abdomen was stood on." After giving birth on August 10, the woman was discharged from hospital after a nurse initialled a section on parent education — which Judge Armitage found was the only time she received any information about safe sleeping strategies, despite engaging with multiple services.
"These tick-a-box initials are the best, and only, documented evidence of safe sleep education being provided to [the] mother," she wrote.
By the end of August, the woman had reportedly broken curfew and other rules at the crisis accommodation facility and was given two weeks to "find alternative accommodation." With nowhere else to go, she was forced to move in with the same sister-in-law who previously assaulted her, her father — described by the coroner as "a dangerous person" who supplied her with cannabis and had also previously assaulted her — along with another adult and five children.
The coroner wrote that the NT Department of Children and Families "must have known that, although the mother was an attentive mother and was tending to [the] infant's needs, her ability to keep [the] infant safe was at risk if she did not have somewhere safe to stay." The department knew the mother was "highly vulnerable with a complex trauma history."