Inquest into the death of Baby RD

Contributing factors

• Non-accidental blunt head trauma inflicted by shaking
• Failure to recognize signs of head injury during weekend hospital presentation
• Delayed reporting to police (12 hours after X-rays showing multiple fractures)
• Inadequate initial police investigation and scene preservation
• Lack of automatic police attendance at resuscitation of young children
• Contradiction between history provided to emergency services and actual mechanism
• Deteriorating conscious state and impaired airway reflexes secondary to severe head injury
• Vomiting and aspiration as contributory to cardiorespiratory arrest

Coroner's recommendations

1. That the Commissioner of Police and the Ministry of Health consider the feasibility of whether there should be an automatic requirement for police to attend premises where NSW Ambulance Service officers are called to attend to a child in circumstances where that child requires resuscitation.
2. That the Commissioner of Police and the Ministry for Family and Community Services consider whether the screening and response priority tool (SCRPT) utilised by the FaCS Child Protection Helpline should include questions whereby the mandatory reporter is asked whether Police have been called or should be called.
3. That the Commissioner of Police and the Department of Family and Community Services and the Ministry of Health consider whether the Child Protection Mandatory Reporters Guide should include a decision tree whereby mandatory reporters are advised to report a matter to the police where they suspect a criminal offence against a child has been committed.
4. That the attention of the Attorney General be drawn to the findings in this matter for consideration as to whether an offence and relevant criminal procedure provisions should be enacted further to the discussion in the NSW Parliamentary Research Service e-brief 12/2014 regarding criminal liability of carers in cases of non-accidental death or serious injury of children.
5. That NSW Health remind its staff of the importance of reporting suspected serious indictable offences against children to both the police and to the Child Protection Helpline and that such reports are made as soon as practicable.