When Tattika Dunn walked into a health centre for a regular check-up on her baby son, a duty nurse thought she was carrying a bag around her belly.
It was actually her three-week-old baby son, Harvey McGlinn, slung low and horizontally around her abdomen.
Unknowingly, at some point between her leaving home and popping in to see a nurse, the fabric sling had suffocated him to death.
What would happen over the next few moments would, in Ms Dunn’s words, tear her heart into ‘a million pieces’ and change practices in baby health advice in New South Wales.
A coroner’s report has laid bare in grim detail how the morning unfolded when Ms Dunn, then 36, arrived for a consultation at the Breast Feeding Service Drop-in Centre at Killarney Vale on the NSW Central Coast on April 8, 2019.
In a report, Deputy State Coroner Derek Lee absolved nurses and medical staff at the centre of any responsibility for the infant’s death – after they did not immediately identify that Harvey was being carried in a sling.
Ms Dunn’s third child, and the baby brother of twin boys from a previous relationship, Harvey had been born prematurely at 37 weeks and four days and just under 3kg, and his weight had fluctuated since.
Baby Harvey McGlinn (above) lived for only three weeks and likely died from suffocation after being carried horizontally in a Boba brand baby sling for a baby clinic visit
Tattika, fiance Bill and their new baby Harvey in 2019 before the tragic death of the infant who is pictured with his twin brothers Seth and Bailey (above), then aged four
Home visit nurses had recommended Ms Dunn consult with nurses throughout his young life, and she carried her young son to his appointment in a blue Boba Wrap baby sling.
According to the coroner’s report, one of the nurses, RN (Registered Nurse) Kovacs saw Ms Dunn arrive ‘walking briskly … wearing a blue, sling-like carrier around her’ with a ‘bulge-like presence’ at the bottom of the sling.
She described the sling as ‘low down’, below the level of Ms Dunn’s belly button, and positioned horizontally.
She said that ‘if at the time she had recognised or believed that there was a baby inside the sling, she would have considered that there was an element of risk involved with the manner in which the baby was being carried.’
Tattika Dunn had stopped en route for coffee at the the Killarney Vale Bakery, about 650m from the health centre, where Harvey in the Boba Wrap was ‘kicking and making noises’.
CCTV footage from the bakery shows her settling Harvey with a pat on the bottom and exiting at 8.52am.
A second nurse, RN Percy saw Ms Dunn arrive at the Centre’s reception at 9.01am.
She ‘did not recognise that Tattika was wearing a baby carrier and instead thought that she was carrying a bag of some kind around her neck’.
A third nurse, RN Mitchell gave evidence that when she first went into the waiting room to call baby Harvey’s name, she ‘initially recognised that Tattika did not have a pram with her and thought that she may have been a client of another allied health service’.
Tattika said after Harvey died his four-year-old twin brothers (above with the infant) ‘loved him more then anything’ and the family was devastated in the wake of the tragedy
RN Mitchell then noted that Tattika ‘had something on her lap which appeared to be very small, and which RN Mitchell did not immediately recognise to be a baby’.
However, ‘when Tattika stood up, she recognised that Tattika was wearing a baby sling and that there was a baby inside the sling, lying across Tattika’s body at the level of her belly button’.
And when told by the nurse she had expected to see a pram, Ms Dunn had responded by pointing to Harvey in his baby wrap and saying, ‘I’ve got him in here’.
She would later explain, Harvey went everywhere in the wrap because he couldn’t lie flat in a pram, perhaps as a result of his ‘horror’ delivery just three weeks earlier, arriving ‘covered in bruises from the forceps’.
‘Every time I laid him flat he would scream straight away. It was like he was in pain. I would say it to the nurses… He never went in his pram,’ Ms Dunn would subsequently tell the Kyle & Jackie O show.
Baby Harvey probably suffocated when he was carried in a sling called a Boba Wrap, which had instruction to keep the baby’s head up and vertical because there was a suffocation risk with horizontal positioning
At that point, the nurse ‘presumed that the baby was asleep as she saw no movement from the baby and did not hear the baby making any sounds’.
In the clinic room, Ms Dunn ‘expressed concern about Harvey being unsettled at night, and experiencing reflux and vomiting over the previous few days’ and ‘spoke about her past domestic history from a former relationship’.
The conversation ‘took up to 15 or 20 minutes’. RN Mitchell asked to have a look at Harvey.
‘Tattika began to unwrap the carrier, exposing one of Harvey’s legs. RN Mitchell noted that Harvey’s skin was white, blue or grey in appearance,’ the coroner’s report says.
‘She also noted that Harvey’s chin was flexed downwards, against his chest, that there was blood around his nostrils, and that the skin around his lips and nose was blue.
‘RN Mitchell immediately recognised that Harvey was unconscious or deceased. She initially went to contact Triple Zero but, upon realising that this would take too long, yelled out, “Emergency”.
‘A call was also made to Triple Zero at 9.29am.’
Tattika Dunn would later tell the KIIS KFM’s Kyle and Jackie O show that as clinic staff frantically tried to resuscitated Harvey, she ‘fell to the floor screaming.
‘I could do nothing to help him. It was horrible, and I was on the floor just watching my baby try to be resuscitated,’ she said, breaking down in tears.
Harvey was placed on a trolley and three different nurses applied CPR, with paramedics arriving at 9.36am and an emergency doctor arriving via a CareFlight helicopter dispatched from Westmead at 9.59am.
Tattika Dunn (above on the Kyle & Jackie O show) said her ‘heart feels like it’s been ripped in a million pieces’ in the months after her son died and that she ‘fell to the floor screaming’ when nurses tried to resuscitate him
Tattika Dunn with her fiance Bill McGlinn, her twin sons Seth and Bailey and newborn Harvey in 2019 before the tragic death of the infant from suffocation inn a baby sling
Baby Harvey could not be revived and was pronounced dead at 10.12am.
A GoFundMe page was set up for Ms Dunn as she and her fiance Bill McGlinn and her twin sons, Seth and Bailey grieved for Harvey.
‘It’s still very raw and my heart feels like it’s been ripped in a million pieces,’ Ms Dunn wrote in a Facebook post following Harvey’s death.
‘On the 8th of last month whilst going for a routine check up with my three week old precious baby boy Harvey passed, it happened for ‘no known reason’ nothing can be explained.
‘A very much loved family member was taken from this world, he had a mum a dad and four-year-old twin brothers who loved him more then anything!
‘When one of our worst nightmares came to play a community stood up and helped do things I just couldn’t, these people are now like family.’
Harvey (left with dad Bill McGlinn) was three weeks old when he died while in a sling at a baby health care centre worn by his mother (right Tattika Dunn)
The Boba Wrap (above) carries a warning label with advice and images entitled ‘SUFFOCATION HAZARD’, stating ‘when using this wrap, constantly monitor your child. Babies younger than four months can suffocate in a wrap if face is pressed tightly against your body’
Ms Dunn declined to be part of an inquest held over two days last month, but there is no suggestion she breached her duty of care.
Deputy Coroner Lee’s inquiry established five key factors to examine for possible causes of Harvey’s death and sought the opinion of a senior staff specialist neonatologist, Associate Professor Nick Evans.
The factors were Harvey’s age and weight, his health and development, the presence of traces of benzodiazepine (anti-anxiety medicine) in his blood, his position in the baby carrier at the time of death, the adequacy of advice to parents regarding the risks associated with baby carriers.
MUM TATTIKA’S TRAGIC MORNING
APRIL 8, 2019:
5:15am: Dad Bill McGlinn leaves home for work, leaving a happy 3-week-old Harvey.
8.20am: Friend Jillian arrives to mind twins Ethan and Bailey, 4, while Tattika takes Harvey to the health centre.
Around 8.40am: Tattika and Harvey arrive at the Killarney Vale bakery where the baby boy kicks and makes noises in his baby wrap and Tattika gives his bottom a pat.
8.52am: Tattika and Harvey leave the bakery and walk 650m to the Long Jetty medical centre for harvey’s appointment.
9.01am: Tattika arrives at the Centre’s reception and sits down.
9.05am: The nurse calls out Harvey’s name and when she asks where’s her pram, Tattika replies ‘I’ve got him in here’.
Tattika goes into the clinic room and speaks with the nurse for 15 or 20 minutes.
Around 9.25am: The nurse asks to look at Harvey, who Tattika pulls from the baby wrap. The nurse sees he is blue around the nose and lips and yells ‘Emergency’.
9:29am: As nurses perform CPR on Harvey, triple-0 is called, and Tattika collapses.
9.36am: Paramedics arrive at the Centre and continue the resuscitation.
9.59am: A CareFlight helicopter arrives with an emergency physician.
10.12am: Despite every effort, baby Harvey is pronounced dead.
Both the Long Jetty health centre staff and the manufacturer of the Boba Wrap sling, Boba Inc, in Wyoming, USA, were also cleared of any liability.
Toxicology results from the autopsy on Harvey found nordiazepam, naproxen (an anti-inflammatory) and paracetamol in the baby’s blood.
However Prof. Evans concluded that ‘the detected levels of postmortem blood samples are much lower than the reported therapeutic levels and therefore would have had no effect on him at the time of his death’.
The professor said baby Harvey’s slow weight gain may have contributed to his death.
Baby Harvey McGlinn (above) did not have sufficient weight to support his neck being held up while he was slung low and horizontally across his mother’s belly button
The NSW coroner absolved all staff at the Long Jetty baby health care centre (above) from any responsibility for the death of baby Harvey McGlinn in April 2019
This was because the baby’s low weight possibly ‘contributed to less muscle and head control (and) the positioning of Harvey’s neck … the most significant factor as to the cause of his death’.
When nurse Mitchell found Harvey dead in the sling, his neck was ‘in a flexed position against his chest’ and had ‘compromised his airway’ probably causing him to asphyxiate.
‘It is more probable than not that the cause of Harvey’s death was positional asphyxia,’ the coroner found.
‘This most likely occurred as a result of the way in which Harvey was being carried inside the sling which did not allow for a patent airway to be maintained.’
The US-manufactured Boba bay wrap, Professor Evans concluded, had provided adequate guidance and warning, but he noted that the effectiveness of safety instructions were based on the premise that ‘firstly people read them (which I suspect they often don’t) and secondly, that everyone who acquires the product will have access to these instructions’.
NSW Deputy State Coroner Derek Lee has found three-week-old Harvey McGlinn (above with his mother Tattika Dunn) most likely suffocated to death because he was incorrectly positioned in a fabric Boba Wrap sling
The coroner noted that at the time of Harvey’s death, NSW Health provided a book to all pregnant women attended their health services, Having a Baby, which advised carrying babies ‘in a safe baby carrier or put them in a pram’
‘Parents and carers should take care when using slings and pouches to carry babies,’ the book says, ‘babies are at risk of suffocation if placed incorrectly in a sling.’
The book goes on to direct readers to online information, including the ACCC product Safety Australia page on baby slings and carriers which states that ‘if used incorrectly, baby slings and framed carriers can lead to rapid suffocation … slow suffocation (or) neck injuries’.
The coroner concludes that ‘evidence establishes that discussions between nurses and parents of newborn babies … did not specifically canvass the use of slings and other fabric baby carriers.
WHAT IS A BOBA BABY WRAP?
The Boba Wrap, which has been sold in Australia since at least 2014, comprises one long strip of cotton and spandex fabric.
It comes with instructions, which ‘require the infant to be placed in the wrap and positioned on the wearer’s chest, vertically, with the infant’s head close enough for the wearer to kiss’.
A warning label attached to the Boba Wrap that Harvey was carried in has written advice and images entitled ‘SUFFOCATION HAZARD’.
It states, ‘when using this wrap, constantly monitor your child. Babies younger than four months can suffocate in a wrap if face is pressed tightly against your body.
‘Babies at greatest risk of suffocation include those born prematurely and those with respiratory problems.
‘Check often to make sure baby’s face is uncovered, clearly visible, and away from the wearer’s body at all times. Make sure baby does not curl into a position with the chin resting on or near baby’s chest. This position can interfere with breathing.’
The Boba instruction booklet also states, ‘IMPORTANT: All babies MUST be carried in an upright, completely vertical position, facing the wearer, even when nothing is covering the nose or mouth’.
Since Harvey’s death, NSW Health has devised a set of instructions for mothers using baby slings to ensure protection with the acronym TICKS (above), which stands for Tight, In view, Close, Keep chin off chest and Supported
‘It is not known what advice and guidance Tattika may have had access to, or been provided with, prior to 8 April 2019.’
Following the baby’s death, the coroner said NSW Health made changes to their advice regarding the risks of baby slings.
NSW Health director of maternity, child and family Deborah Matha spoke at the inquest saying banning slings was the only way to completely eliminate the risk but admitted that would be almost impossible to do due to cultural and disability reasons for mothers wearing slings.
The acronym ‘TICKS’ has been devised since Harvey’s death as a way to ensure other parents avoid the same accident. TICKS stands for Tight, In view, Close, Keep chin off chest and Supported.