An inquest into the death of a seemingly healthy three-month-old baby, known as KP, has concluded without determining the cause of death. NSW Deputy State Coroner Kasey Pearce stated, “It is tragic, but we simply don’t know what happened to KP,” following the baby’s discovery at his mother’s home in Corowa, New South Wales, in January 2022.
The inquest considered various possible causes of death, such as drowning, suffocation, and inadequate nutrition, but found no sufficient evidence to support any of these theories. Coroner Pearce expressed that the available information was insufficient to establish the circumstances surrounding KP’s death, stating, “Unfortunately, the result is there is no evidence leading up to the death of KP.” She further scrutinised the mother’s account of events, finding it “implausible and inconsistent,” particularly regarding the involvement of an unidentified man in KP’s care.
Pearce affirmed that although the Coroners Court lacked insights into KP’s developing personality, it was clear that he was cherished by his family, adding, “Until his premature death, he seemed to be thriving.” The inquest reviewed the actions of organisations responsible for supporting KP and his mother, including the Department of Communities and Justice, the Murrumbidgee Local Health District, and Albury Wodonga Health. While some deficiencies in their actions were noted, Pearce concluded that these shortcomings did not indicate that KP’s death could have been prevented, commending the professionalism and care exhibited by those involved.
Prior to KP’s birth, a risk assessment identified his mother’s mental health and drug use as concerns. Despite these risks, KP was considered “safe with a plan,” contingent upon the support of social services. However, Pearce indicated that red flags emerged post-birth, with the mother missing numerous appointments and sometimes refusing entry to visiting social workers, even when they communicated their schedules in advance.
In light of the inquest’s findings, Pearce recommended that the NSW Health SAFE START program enhance its governance and clarify roles and responsibilities. This program is aimed at providing care and early intervention for pregnant women and their infants and was responsible for assisting KP and his mother.
On January 12, 2022, a relative reported hearing baby cooing sounds in the granny flat where KP lived, marking it as the last confirmed instance of his life. Pearce’s inquest serves as a reminder of the complexities and challenges surrounding child welfare and care in vulnerable situations, leaving many questions still unanswered.