A Coroner has ruled that the 2-month-old boy was not properly secured in his baby capsule, causing him to slip out and sustain the fatal injury as his father went to place him in the family vehicle.
She said that had the baby been properly secured in the capsule, the tragedy would not have occurred.
Baby Harsimar died on June 19 2019.
He was in a capsule fitted to a pram, but slipped out when his father removed the capsule to transfer it to the back seat of the car.
Harsimar landed on a piece of glass from a feeding bottle that also toppled from the carrier, smashing on the concrete.
The glass penetrated the top of his head causing a fatal injury.
Harsimar was rushed to Starship Children’s Hospital and died soon after.
Harsimar’s death was referred to Coroner Tracey Fitzgibbon whose findings have now been released to the New Zealand Herald.
The day of the tragedy, Harsimar’s parents - who were not named in the Coroner’s report - took him to SkyCity in central Auckland, parking in the onsite car park and spending two hours at the complex.
When they returned to the car the tragic incident unfolded.
“Almost immediately after the bottle fell Harsimar has slipped out of the capsule and fallen to the ground,” said Coroner Fitzgibbon.
“The back of his head has struck the broken bottle and caused a cut to his head. Harsimar was transported to hospital but died from his injuries.
“Harsimar was not strapped into the capsule... Police are of the opinion Harsimar died as a direct result of a fall caused by incorrect carrying of the capsule combined with not being adequately secured in place.”
Police confirmed there were “no untoward or suspicious circumstances” regarding Harsimar’s death and no one was or would be charged.
Coroner Fitzgibbon then opened an inquest in a bid to ascertain exactly how the baby died, if that death was preventable and if there were any recommendations she could make public to stop similar tragedies in future.
She said Harsimar’s father knew how to properly secure his baby into the capsule and how it locked in and out of the pram and car.
On the day, when he detached the capsule from the pram, he did not know the harness was not secured to stop Harsimar from falling out due to him being covered by a blanket.
“Harsimar’s mother confirmed that while they were at Sky City she was feeding Harsimar multiple times and therefore took him out of the capsule many times,” said the Coroner.
“Before they went to the car park, she was the last person to put Harsimar inside the capsule and says his safety harness was not secured as it was irritating Harsimar and he was sleeping.”
The capsule was inspected by a certified NZQA/NZTA-approved child restraint trainer.
He confirmed that the capsule was functioning as designed and there were no faults - and that Harsimar was “not correctly harnessed into the restraint”.
Further, a handle on the capsule was not in the correct position when removed from the pram meaning “the balance and security of the child and the capsule was significantly compromised”.
“Had the handle been in the correct position and the child correctly harnessed in, even if the capsule fell it is unlikely the child would have sustained significant injuries,” the expert said.
After looking at all the information Coroner Fitzgibbon ruled Harsimar’s death was “a tragic accident” but could have been prevented.
“Not only was the handle not in the recommended position but the harness was not in place securing Harsimar into the capsule,” she said.
“Had he been correctly harnessed in the capsule it would have functioned as designed and he would not have fallen out.”
The Coroner made comments aimed at preventing similar deaths in future.
“It is important for those using a capsule to familiarise themselves with the manufacturer’s manual and ensure the capsule is always set up in the correct manner, while in a motor vehicle and when the capsule is being used outside a motor vehicle,” she said.
“As well as the manufacturer’s instructions, there is a range of information available online about the correct type and use of infant capsules and car seats. I encourage families to read this information or contact a child restraint technician.”
The Coroner’s findings were provided to NZTA, Safekids Aotearoa and Plunket “for consideration whether their specific education around infant capsules can be extended to include ‘out of vehicle’ safety when using infant capsules”.
*At the time of the incident reports incorrectly stated a baby girl had died.
