It was there that she died from suspected Sudden Unexpected Death in Infancy (SUDI) after being fed by her caregivers and put down for a sleep.

Today, at the coronial inquest held in Wellington, the surrounding events leading up to Chloe’s death are under the microscope in an effort to establish a cause.

Approximately one week after her birth, the Family Court at Palmerston North granted an interim custody order and Chloe was placed into the custody of two experienced CYFS-approved caregivers.

At the time, the couple, who have name suppression, had fostered 107 children in 23 years, but had in the last eight years only been taking care of babies.

At approximately 2.30pm on June 6, 2016, after feeding Chloe, her foster mother put her down for a sleep in her bassinet.

At 5pm, the woman came in to check on the baby and found her still asleep. Twenty minutes later, she returned to the room and talked to Chloe, but she didn’t react, and was pale with a blue tinge to her lips.

Chloe’s caregivers began CPR and called an ambulance, but she was unable to be resuscitated and was pronounced dead at the property.

Police investigated and found the death was not suspicious, but because her death was unexpected, it was referred to the Coroners Court, where, at the time, it was mandatory for an inquest to be held if a person died while in state care.

Nine years later, an inquest was finally held into Chloe’s death. Her father travelled from Timaru for the hearing, but her mother did not wish to attend.

‘This is not a result of a previous brain injury after this child was born’

A forensic pathologist, Kate White, told the coronial inquest that following an autopsy, which is more extensive when performed on babies, there was no evidence of any injury of any kind.

White’s conclusion was that Chloe had died from SUDI, because there was no obvious cause.

She said there was some white matter gliosis found in Chloe’s brain, which was a form of scarring, which was common in babies who had died from SUDI.

White said that it was a kind of cellular damage that no one really knew how it occurred, but current literature theorised that it occurred while in utero.

“The cause is not truly understood,” she said.

“We should think about it like a cellular insult, rather than a traumatic injury.”

When asked if gliosis could be caused by a baby being shaken, White said that there would be other obvious signs if that were the case.

“This is not a result of a previous brain injury after this child was born.”

White said that white matter gliosis was perhaps best thought of as a possible vulnerability in babies who had died of SUDI.

‘It didn’t kill Chloe immediately’

One of New Zealand’s leading experts in SUDI, Dr Edwin Mitchell, who helped a landmark research called the Cot Death Study, also gave evidence.

That study found that babies who were put to sleep on their stomachs were more likely to die, as were babies who lived in homes with smokers, or whose mothers smoked during pregnancy.

On the whole, though, he said diagnosing SUDI was a process of exclusion and was defined essentially by the absence of any other factors.

Mitchell said that Chloe didn’t have any of the common risk factors common to babies vulnerable to SUDI. She slept on her back, wasn’t bed sharing, and there were no drugs or alcohol in the home, wasn’t low birth weight and was ethnically European.

“I couldn’t identify any factor that would be in that group of intrinsic factors.”

Mitchell said that the only factor he could identify was that she was at a critical age where the majority of SUDI deaths occur.

He noted that there are roughly 50 similar deaths per year, six of which will not have an identifiable factor. Mitchell said Chloe was in this category.

As for the scarring found on the white matter in Chloe’s brain, Mitchell said it was possible that something happened in the womb that caused a lack of blood flow to her brain.

“It didn’t kill Chloe immediately,” he said, but noted that it could have damaged parts of her brain that were important for breathing.

“It might just make the baby more vulnerable.”

Mitchell said it was something that was seen in SUDI cases, that was not seen in babies who had died due to other means.

“Is it the primary cause … well it’s possibly the primary cause. I can’t say,” he said.

“It seems more likely that the brain has been injured at a cellular level, it may just be a marker for that.”

Coroner Robin Kay said that SUDI left parents who had lost an infant with many questions that medical science currently couldn’t answer.

“I hope one day that will change,” he said.

Coroner Kay said that while the evidence didn’t explain why Chloe had died, he hoped that it brought some comfort because it showed she didn’t die because of something someone had done to her.

He will deliver his written findings at a later date.

Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.