A BABY girl suffocated to death under bedding around the time her parents, who had smoked cannabis, were engaging in sexual activity in the same bed, a coroner has found.
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Coroner Olivia McTaggart released her findings into the death of the 11-month-old, who cannot be identified for legal reasons, in Launceston on Wednesday.
The coroner criticised the baby's parents, Child Protection Services and the agency's over-reliance upon advice from Gateway Services.
She made 12 recommendations for child protection, including recommending they conduct regular audits of files, and two recommendations for Tasmania Police in relation to family violence incidents.
Ms McTaggart said she intended to refer her findings, together with the evidence at inquest, to the Director of Public Prosecutions to determine whether either parent should face criminal charges in relation to their daughter's death.
A five-day coronial inquest took place in Launceston and Hobart last year.
Ms McTaggart found that the infant died early on January 27, 2013, likely between 2am and 3am.
She said the parents were aware they had likely rolled onto their baby while engaged in sexual activity, but neither bothered to check the infant.
"I cannot determine to the requisite standard whether . . . [the] death occurred before, during or after the sexual activity," the coroner said.
"Commonsense would suggest that the suffocation was more likely to have occurred whilst she was trapped under the bedding, by or in proximity to adult bodies."
Ms McTaggart condemned the parents' conduct as "uncaring and irresponsible in the extreme" and said what they told authorities was "inconsistent, contrived and, in many respects, fanciful".
"They were fully aware of a potentially dangerous situation created solely by their own actions and blatantly ignored her safety," the coroner said.
She said if the law had required her to find who contributed to the baby's death, she would find that both parents contributed.