Child Fatality Summary

Child's Name: County: Duval

Date of Birth: Date of Death: March 27, 2018

Report Number: 2018-487553

Family Composition Chart

Age at Time
Name of Incident Relationshi with Deceased Child
7 months Deceased Child
22 Mother
2 Siblin
44 Maternal grandmother
27 Maternal uncle

1. Circumstances Surrounding Death

March 27, 2018, seven-month-old- was found unresponsive in her mother's bed . The
mother routinely shared her adult ~- On this date, the mother l e f t _
sleeping on her bed with pillows around her when she went to work around 7:30am. The uncle
was sleeping elsewhere in the home and was the careg iver while
the mother worked. The uncle woke at approximately 11 :00 am and went to check on
initially the uncle could not f i n d - on
her mother's bed because the room was dark. He turned on the lights and observed -
between the headboard and bed face up. He yelled - name, took her downstairs and
placed her on the sofa. He immediately called 911. The 911 operator walked him through
cardiopulmonary resuscitation (CPR) procedures and he p l a c e d - on the floor as he
administered CPR until emergency medical services (EMS) arrived. When EMS arrived, -
was still unresponsive. She was transported to Memorial Hospital where she was declared
deceased at 11 :54 am.

The Jacksonville Sheriff's Office responded to the home and conducted the criminal
investigation. They reported finding nothing of concern regarding the home or family members
and found no evidence to suggest abuse or neglect. The child's death was ruled an accident and
the law enforcement investigation was closed July 24, 2018, with no criminal action taken.

The Medical Examiner completed an autopsy which determined the cause of death to be sudden
unexpected death in infancy, associated with unsafe sleep factors (including adult bed and
unsafe posture/wedging) with probable asphyxia. The manner of death was an accident.

The First Coast Child Protection Team reviewed the medical files and the Medical Director
concluded there was evidence of fatal neglect noting the mother co-slept with the child and left
the child on her bed surrounded by pillows which led to positional asphyxia. Medical records
confirm the mother had been advised against bed sharing and unsafe sleep environments.

Based on the information obtained during the investigation, the Department of Children and
Families, Child Protective Investigations closed the abuse investigation on July 25, 2018, with no
indicators of death due to inadequate supervision. While the mother did make a poor parenting
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 Fatality Summary

decision to place her child in an adult bed to sleep despite being told by several professionals
about the risk of unsafe sleep, this decision does not rise to the level of neglect due to
inadequate supervision.

2. Other Children in the Family

had one sibling at the time of her death, was determined to

be safe in the care of his family and no service needs were identified for him. The mother was
offered a referral for grief counseling but did not engage with this service.

3. Summary of Prior Agency Involvement with Family

The family does not have any prior abuse report history with the department

__________
Child Fatality Prevention Specialist

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