Provincial court Judge John Henderson is also recommending the province research and update its policies for the use of bassinets by foster parents.
His inquiry report, released Wednesday, examines the death of Phoenix Majestic Omeasoo. The six-month-old girl suffocated in a collapsed bassinet in Edmonton in 2010.
Provincial court Judge John Henderson ruled the death was accidental and "caused by the confluence of a number of factors, none of which on their own would have resulted in the death."
He said that the baby's foster parents improperly placed the bassinet on its metal stand and did not attach it with clips. The bassinet was then placed near a crib and a two-year-old foster child probably reached over and pulled the bassinet down.
"The basket came to rest with the foot portion of the basket higher than the head portion. This caused Phoenix to slide to the end of the basket and come to rest in a way which prevented normal breathing."
In 1988, a child in the same foster home drowned in a swimming pool. But the judge said the death was not relevant to this inquiry.
He described the foster parents as "devoted and loving," although perhaps stretched to capacity, as they had eight children in their home at the time of Phoenix's death, some with special needs.
They hadn't planned to keep Phoenix in the bassinet for long, said the judge. They had bought her a crib but were waiting for a custom-ordered mattress to arrive.
Since the girl's death, Health Canada has recommended bassinets not be used for a babies who can roll over or who have reached the manufacturer’s recommended weight limit.
In 2011, Alberta also eliminated the use of bassinets by foster parents, with some exceptions for temporary use, said Human Services Minister Heather Klimchuk.
"We are always looking for ways to improve the system," she said.
"My department is already reviewing the (judge's) recommendations to determine whether further changes should be made to our policies or practices to prevent similar deaths in the future."