Coroner's Court of Western Australia

Inquest into the Death of LCTM

Inquest into the Death of LCTM

Delivered on :25 June 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

There is a suppression order in place in relation to the deceased’s name for the purposes of publication. The deceased is generally referred to as LCTM Baby L or the baby throughout the finding.

There is a suppression order in place in relation to the deceased’s father’s name for the purposes of publication. He is generally referred to as LCM or Baby L’s father throughout the finding.

There is a suppression order in place in relation to the deceased’s mother’s name for the purposes of publication. She is generally referred to as CTB or Baby L’s mother throughout the finding.

Summary : The deceased was born six weeks premature on 21 January 2014. He remained in hospital for several weeks after his birth for medical reasons relating to his prematurity.  The deceased was the first child of his teenaged parents.  The deceased’s father was in the care of the CEO of the Department of Child Protection and Family Support and he had a history of substance abuse, violence and crime.  His relationship with the deceased’s mother was highly volatile and suspected of being marred by domestic violence.

The Department of Child Protection and Family Support became involved with the family for signs of safety planning after the birth.

On 5 February 2014 the Department decided that there was insufficient evidence to take action to remove the deceased from his parents’ care and a plan was developed for him to be discharged home with his parents. This was despite a Code Black incident involving the deceased’s father at the hospital.

On 15 February 2014 the deceased’s parents collected the deceased from the nursery and took him to their room at the hospital. His mother left the room leaving the deceased alone with his father.  This was the first time the deceased’s father had been alone with him.  In a timeframe of three to ten minutes the deceased’s father deliberately struck the deceased’s head against a hard surface in the room with considerable force at least twice.  These blows fractured the deceased’s skull and caused severe brain injuries.  The deceased’s father did not go and seek assistance for him but remained with him in the hospital room.

The deceased’s mother returned to the room and realised the deceased was not breathing. She rushed him to the nursery where efforts were made to resuscitate him.  The deceased was subsequently transferred to Princess Margaret Hospital for further treatment.  Sadly the deceased could not recover from his injuries and he died.

The deceased’s father was subsequently charged and convicted of manslaughter in relation to the death. The father was later found to have FASD, which raised questions about whether an earlier diagnosis would have affected the outcome.

Catch Words : Code Black : Care and Protection : Unlawful Homicide.


Last updated: 10-Jul-2018

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