An eight-month-old who had been in the care of a Child Youth
and Family caregiver for a week died suddenly when she became
tangled in the blankets she was sleeping in, a coroner has
Alexis Green had been urgently placed into the care of Child
Youth and Family (CYF) in Christchurch on October 4 last year
after police were called to her 23-year-old mother's home
three times in one night.
For six years the Ministry of Social Development (MSD) had
been aware of Alexis' mother, whose six children had been in
and out of CYF care.
On October 4 Alexis was urgently placed into a CYF
caregiver's care, a coroner's report released today said.
The caregiver, identified only as Ms A, had been assessed as
being a suitable caregiver in September 2009 and a review in
September last year recommended that Ms A was best suited to
provide transitional care for 7 to 10-year-old girls, Coroner
Sue Johnson said.
The social worker who carried out this assessment did not
transfer her recommendation to the computer system.
On October 4, when another social worker looked at Ms A's
file, she saw nothing about the age recommendation.
On the night of October 10, Ms A put Alexis to bed on her
back and with three cot blankets placed over her. The
blankets were not tucked in.
Later in the evening Ms A checked on Alexis and put two extra
blankets on her and pulled the blankets up to her chest.
At 7am the next day, Ms A found Alexis face down with the
blankets tight over her head with her knees pulled up under
Ms A saw that Alexis was purple and called emergency services
but she was pronounced dead.
Forensic pathologist Martin Sage determined Alexis died of
sudden unexpected death in infancy due to accidental asphyxia
in an unsafe sleeping position.
Since Alexis' death a CYF practise review was commissioned
and completed. It recommended that whenever caregivers were
assessed or reviewed, a CYF worker must sign off that notes
about the assessment were on the computer database.
Since the report was commissioned staff had taken action to
remedy unsafe sleeping arrangements after talking with
caregivers, Coroner Johnson was told.
Kelly-Marie Anderson, the regional director of the southern
region of CYF, said CYF was now expert at developing policies
to respond to child abuse and neglect but it was not expert
in terms of policies about general safety and well-being and
health of children.
Ms Anderson was hopeful that with external expert assistance
the Ministry could implement national requirements for safe
sleep practises and environments for babies in CYF care.
Coroner Johnson compiled a vast list of recommendations for
her report, released today, aimed at the MSD, the Ministry of
Health and the Social Workers Registration Board.
The recommendations included:
• The MSD develop national pro-active policies which
would embed knowledge, understanding and skills about safe
sleeping practises into the day to day business of CYF.
• MSD seeks external advice about how to educate CYF social
workers and caregivers.
• Staff and caregivers receive regular training.
• That MSD sets a goal to have all placements for babies
• That the Ministry of Health launches an advertising
campaign to promote safe sleeping principles.
Between July 2007 and April 2012 there was 212 sudden infant
deaths in New Zealand.
In 30 of those cases a coroner found that the death was
caused by asphyxiation during unsafe sleeping.