Introduction

A 5-month-old infant placed to sleep in a partially inflated plastic bed was found, unresponsive, with her face pressed against the plastic in a trough created between the base and the side of the inflatable bed (1). The infant's death was attributed to suffocation. Byard (2006) reviewed the circumstances of this death and recommended assessment of these types of inflatable beds by product safety experts (1).

Details about the circumstances and cause of this death were also collected by the South Australian Child Death and Serious Injury Review Committee, which undertook its own in-depth review. The result of this review was to recommend to the South Australian government that it request the relevant national regulatory body to amend regulations about children's portable cots to incorporate the requirement that “no component of a portable folding cot be inflatable” (2). This change in national regulations was achieved three years after the infant's death.

Child Death Review in South Australia

Since 2005, the Child Death and Serious Injury Review Committee (“the Committee”) has been responsible for reviewing the circumstances and causes of all child deaths in the state of South Australia. Similar teams and committees are now well established in other states and territories in Australia and in other countries including Canada, New Zealand, the United Kingdom, and the United States.

In South Australia, the Committee consists of a multidisciplinary team with expertise in fields such as pediatrics, education, disability, psychology, social work, child protection, public health, and justice who come together to consider the information that has been gathered about an infant's death. This broad base of knowledge and experience leads to a comprehensive overview of the circumstances of the death and identification of systemic issues that may have contributed to the quality of service provision to that infant and their family. The review process can also identify the absence of particular services, or of regulatory or legislative mechanisms which, if present, may have resulted in a different outcome for the infant.

At the conclusion of a death review, the Committee can make recommendations to government about changes to legislation, policy, or practice which could potentially lead to a reduction in the risk of deaths occurring under similar circumstances, such as the change to portable cot regulations.