FINDINGS INTO DEATH WITHOUT INQUEST [cont.]

Deceased: Baby BD

Cause of death: 1a: DROWNING

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED (cont.)

11. Both LD and AD were aware that the pool gate had been faulty for some years. The gate had been earmarked for repair; however, this had not occurred prior to the time of BD’s death. LD recalls securing the pool gate closed with a heavy pot plant upon exiting the pool enclosure on the morning of BD’s death, as was their common practice. LD believed she had closed the back sliding door upon returning inside the house.

12. LD had been experiencing difficulty with insomnia leading up to the day of BD’s death. LD was unable to definitively confirm that she had taken mirtazapine the morning of BD’s death; however, she confirmed that she had previously taken a mirtazapine tablet on several mornings when she had been unable to sleep the night prior and that it was possible she had done so on this occasion. A mirtazapine blister pack was noted by police on the kitchen bench beside a glass of water, and a blood test subsequently confirmed the presence of mirtazapine in LD’s and BD’s bloodstreams.

13. LD gave BD lunch followed by a breastfeed at approximately 12 noon, then placed BD in his cot in his bedroom at the front of the house for his lunchtime nap at about 12.30 p.m. LD lay down on the couch and fell asleep. BD’s lunchtime naps were usually of 1–2 hours duration.

14. On waking at 3.30 p.m., LD entered BD’s bedroom and noted that he was no longer in his cot. LD reported that BD had been able to self-extricate from his cot for a period of approximately four weeks prior to his death.

15. LD checked through the house and noted that the back sliding door was open, offering direct access from the house to the pool enclosure. AD reported that he and LD were in the habit of leaving the back door open on hot days for the breeze; however, they were always careful to supervise BD at these times as there is direct access to the street via the side of the house.

16. LD reported that she found the pool gate wide open when she entered the pool enclosure. It was subsequently noted by police attending the scene that the gate had been propped ajar with a pot plant. Both AD and LD were unaware of how the pot plant came to be in the position of propping the gate open, rather than its usual position of securing the gate closed.

17. When LD entered the pool enclosure, she saw a shape at the bottom of the pool and jumped into the water, retrieving a body and identifying it as her son BD. She subsequently commenced CPR, calling emergency services at 3.45 p.m.