A three-week-old boy most likely suffocated to death while pressed against a fabric sling worn by his mother, a NSW coroner has revealed.
Harvey McGlinn was found pale and motionless when his mother unwrapped the sling at Long Jetty health centre on the Central Coast in 2019.
Staff at the centre frantically performed CPR on the baby, but Harvey could not be revived.
“The evidence establishes that the position of Harvey‘s neck, with his chin on his chest, compromised his airway,” the coroner said in his findings delivered on Thursday.
The newborn was Tattika Dunn’s first son with fiance Bill McGlinn. She has twin four-year-old boys Seth and Bailey to another father.
“It’s still very raw and my heart feels like it’s been ripped in a million pieces,” Ms Dunn wrote in a Facebook post a month after her son’s death.
She declined to be involved in the inquest. There is no suggestion of a breach of duty of care.
“Harvey’s relatively low weight may have resulted in less muscle and head control resulting in a difficulty in maintaining a patent airway from the way that Harvey was positioned in the sling,” the coroner said.
On the day of Harvey’s’ death, a nurse from the healthcare centre saw Ms Dunn “walking briskly towards the centre” wearing a “blue, sling-like carrier”.
RN Kovacs – as she is known in the coroner’s report – said she saw a “bulge-like presence” at the bottom of the sling that was “low down”, below the level of Ms Dunn’s belly button.
The health centre staff and product manufacturer were both cleared of any liability over the death.
The product included a suffocation warning and an instructional booklet that warned that babies needed to be carried upright with their chin off the parent’s chest.
Witnesses told the coroner that Harvey’s entire body was inside the loosely fitted sling.
NSW Health had since made changes to advice about the risks of baby slings, the coroner said.
NSW Health director of maternity, child and family Deborah Matha told the inquest that in 2019 there was not a “great deal” of information from NSW Health regarding the use of slings for safe sleeping.
Ms Matha said banning slings might be the only way to eliminate their risks.
However, she noted that this would be hard to do, as they were customary in some cultures and some disabled people relied on them as a necessity.
The acronym, TICKS, has been devised to help parents avoid the same devastating loss.
It stands for Tight, In view, Close, Keep chin off chest and Supported.
Tight: The sling should be tight, with the baby positioned high and upright with head support. Any loose fabric might cause your baby to slump down, which could restrict breathing.
In view at all times: You should always be able to see your baby’s face by simply looking down. Ensure your baby’s face, nose and mouth remains uncovered by the sling and/or your body.
Close enough to kiss: Your baby should be close enough to your chin that by tipping their head forward you can easily kiss their head.
Keep chin off the chest: Ensure your baby’s chin is up and away from their body. Your baby should never be curled so that the chin is forced onto their chest. This can restrict breathing. Regularly check your baby. Babies can be in distress without making any noise or movement.
Supported back: Your baby’s back should be supported in a natural position with their tummy and chest against you. When bending over, support your baby with one hand behind their back. Bend at the knees, not at the waist.
The inquest found it was not clear whether any posters displaying safe sleeping practices were ever displayed at the Long Jetty healthcare centre prior to April 8, 2019.
In the wake of Harvey’s death, the Australian Competition and Consumer Commission (ACCC) has prioritised implementing strategies for unsafe infant sleeping products.
8 APRIL 2019: EVERY PARENT’S NIGHTMARE
APRIL 8, 2019
5.15am Harvey’s father Bill McGlinn leaves for work.
8.20am Tattika’s friend Jillian arrives to mind her twin sons Seth and Bailey, 4, so that his mother Tattika can take Harvey to a healthcare centre for unsettled sleep, reflux and vomiting over the previous few days.
8.40am Tattika arrives at Killarney Vale bakery where she said Harvey was kicking and making noises in his baby wrap.
CCTV shows Tattika giving his bottom a pat.
8.52am Tattika walks 650m to the Long Jetty healthcare centre for Harvey’s appointment.
9.01am They arrive at the reception and take a seat. Witnesses report seeing Harvey lying horizontal across Tattika’s stomach inside the sling.
9.05am The nurse calls out Harvey’s name but Tattika doesn’t respond at first, thinking her own name would be called.
Harvey’s name is called again, this time Tattika responds. The nurse asks where her pram is and she replies ‘I’ve got him in here’, pointing to the sling.
Tattika is inside the clinic room for 15 to 20 minutes speaking to the nurse.
9.25am The nurse asks to look at Harvey and Tattika unwraps him from the sling. Immediately the nurse sees his skin is a blue-grey colour and his body is motionless. She yells out to the healthcare staff that there is an emergency and begins performing CPR.
9.29am Triple-0 is called and Tattika faints from the distress.
9.36am Paramedics arrive and continue trying to revive Harvey.
9.59am A CareFlight helicopter arrives with an emergency physician on-board.
10.12am Baby Harvey is pronounced dead at just three weeks old.