The mother of a newborn baby who died in an unsafe sleeping environment in overcrowded housing in Alice Springs two years ago was effectively homeless after being evicted from crisis accommodation six days earlier, a coroner has found.
The six-week-old Aboriginal girl, who is not named in the findings, died from a condition known as sudden unexpected death of an infant (SUDI) in September 2024.
The condition is distinct from the more widely-known sudden infant death syndrome (SIDS), which is only diagnosed when a death cannot be explained by a baby's sleeping environment.
In releasing her report without holding an inquest, Northern Territory Coroner Elisabeth Armitage said the girl's mother, 21, who was also not named, was "known to be a good mother who was attentive to her infant's needs".
Despite being "well known to various agencies", she was evicted from her accommodation "into effective homelessness" and "no safe sleep space for [the] infant was provided", meaning they were forced to sleep together on a single mattress on a relative's lounge room floor.
Judge Armitage said after falling pregnant in January, the woman was assaulted by her brother and sister-in-law, during which she was "pushed to the ground, punched in the face and her abdomen was stood on".
When she gave birth on August 10, the woman was discharged from hospital after a nurse initialled a section on parent education, which Judge Armitage found was the only time she received any information about safe sleeping strategies, despite engaging with multiple services.
"These tick-a-box initials are the best, and only, documented evidence of safe sleep education being provided to [the] mother," she wrote.
Department 'must have known'
By the end of the month, the woman had reportedly broken curfew and other rules at the crisis accommodation facility she had been discharged to and was given two weeks to "find alternative accommodation".
With nowhere else to go, the woman was forced to move in with the same sister-in-law who previously assaulted her, her father — "a dangerous person" who was supplying her with cannabis and had also previously assaulted her — along with another adult and five children.
"The [NT Department of Children and Families] (DCF) must have known that, although the mother was an attentive mother and was tending to [the] infant’s needs, her ability to keep [the] infant safe was at risk if she did not have somewhere safe to stay," Judge Armitage wrote.
"To support the safety of [the] infant, it was incumbent upon the department to continue to deliver services and/or to ensure appropriate services were actually actively engaging with mother and infant to safeguard [the] infant."
On the morning of September 22, the woman woke to find her baby limp and cold to the touch, with blood coming from her mouth.
Emergency services were called but she could not be revived and was declared dead less than an hour later.
Child removal 'not an answer'
Judge Armitage said the department "should not have turned a blind eye to [the] mother’s predicament and the sleeping risks this created for [the] infant".
"To be clear, child removal is not an answer to homelessness," she said.
"This 21-year-old single mother was attentive, caring and protective of her infant.
In response to a draft of the findings, the department said "consideration of financial support for [the] infant and her mother should have been made" to help her secure safe accommodation.
"There was discretion for the DCF to fund interim accommodation for [the] infant’s mother and [the] infant until a more suitable arrangement could be made," it said.
"Since 1 July 2025, investment in homelessness services has increased through the National Agreement on Social Housing and Homelessness and a stronger accommodation continuum is now available for young people, young parents and families."
Nation's highest infant mortality rate
The child's death was the eighth SIDU death examined by the NT coroner's office this year alone and Judge Armitage held inquests into the deaths of three of those babies in Alice Springs and Tennant Creek, delivering her findings in April.
The NT has the highest infant mortality rate in Australia at 6.53 deaths per 1,000 people, almost double the national average of 3.27 deaths per 1,000 people.
In her latest findings, Judge Armitage repeated her previous recommendations around providing culturally appropriate education on safe sleeping practices and that services take reasonable steps to identify where an infant might be at risk of SUDI.
She also recommended the NT government "identify, quantify and map the level of homelessness experienced by expectant and new mothers" throughout the territory and called for "access pathways to suitable accommodation" to be established and funded along with prioritising Aboriginal community controlled service delivery.
"I recommend to the Department of Children and Families that it review and amend all relevant policies, practices and procedures to ensure that investigations or engagements with families are not closed prematurely," she wrote in both sets of findings.
The NT government has been contacted for comment.
