Inquest into the Death of Baby H (Name Subject to Suppression Order)

Inquest into the Death of Baby H (Name Subject to suppression Order)


Delivered on :9 February 2021

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations :Yes

Recommendation No. 1

I recommend that the Western Australian Government considers the undertaking of a regulatory impact review and if appropriate, introduces:

Recommendation No. 2

In order to improve communications between its staff and third parties, the Department should include information regarding the appropriate contact details for its staff (including after-hours) in its High Risk Infant Policy.

Recommendation No. 3

In order to provide an appropriate level of support to family members, the Department should prepare a policy document that sets out the practices and procedures to be followed in relation to family members after the death of a child who was in the Department’s care.

Orders/Rules : N/A

Suppression Order : Yes

Suppression of the deceased’s name from publication and any evidence likely to lead to her identification. The deceased is to be referred to as Baby H.

Summary : On 28 May 2017 Baby H died at Princess Margaret Hospital from head and neck injuries She was 4 months and 9 days old. Two days before her death she was placed into the care of the Department of Child Protection and Family Support.

In mid-April 2017 bruising was noticed by a family member on Baby H’s cheekbone under her eye, on her forehead above her eye and on her chin. Slight bruising to Baby H’s face had been observed on 24 March 2017 and 4 May 2017 during Child Health Nurse appointments. A report of the bruising was made to the Department of Child Protection (Department) on 10 May 2017. Two Child Protection Workers from the Department attended at Baby H’s home on that day and observed bruises on Baby H. The Child Protection Workers were told by Baby H’s mother that the bruising had occurred when Baby H hit her head on her cot. The Child Protection Workers directed Baby H’s mother to take her to the Bunbury Regional Hospital for an examination, which she did.

An Emergency Department Triage Assessment on Baby H was completed between 8.21 pm and 8.25 pm. Concerns were raised by the treating nurse when the explanation provided by the mother as to how Baby H’s injuries were sustained. The treating nurse raised her concerns with a fellow nurse and her nursing co-ordinator who reviewed Baby H and came to the conclusion that her bruising was accidental and she was discharged into her mother’s care. The Department was notified that the hospital had accepted the mother’s explanation for the bruising, and later that day Department workers attended at Baby H’s home, delivering a cot bumper and discussed future care and a safety plan for Baby H.

On 20 May 2017 further bruising on Baby H’s neck was noticed by a family member and Baby H’s mother was urged to have Baby H medical examined. Baby H’s mother did not seek medical assistance on this occasion. A home visit was scheduled by the Department for 25 May 2017 but due to work pressure the visit was re-scheduled to the following day.

At about 8.00 am on 26 May 2017 Baby H’s father found her unresponsive in her cot. An ambulance was called and Baby H was taken to the Bunbury Regional Hospital. Baby H was then flown to Princess Margaret Hospital and admitted to the Intensive Care Unit. Despite all attempts to save her life, Baby H died on 28 May 2017.

Baby H’s mother subsequently pleaded guilty to Baby H’s murder and she was sentenced to life imprisonment.

The Coroner made three recommendations aimed at addressing mandatory reporting of injury to non-ambulant infants, to improve communications between Department staff and third parties and a recommendation to establish an appropriate level of support to family members after the death of a child who is in the Department’s care.

Catch Words : High Risk Infant Policy : Training : Mandatory Report of Injury to non-ambulant infants : Unlawful Homicide

Last updated: 22-Apr-2022

[ back to top ]