Coronial
NSWhome

Inquest into the death of HB

Deceased

HB

Demographics

1y, female

Coroner

Decision ofDeputy State Coroner Forbes

Date of death

2018-06-19

Finding date

2024-12-04

Cause of death

Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blood in abdominal cavity)

AI-generated summary

A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive facial injuries on 13 June attributed to bumping into her mother's chest. At both presentations, medical staff found the explanations implausible or concerning. Systemic failures included: inappropriate routing of child protection notifications away from specialist joint investigation response teams; passive acceptance of medical opinions suggesting injuries were 'bizarre but possible' without adequate challenge to likelihood; hospital discharge despite child protection agency request to retain the child; and delayed activation of multi-agency investigation. A maxillo-facial surgeon's opinion that the mechanism was 'bizarre but possible' was relied upon without adequate consideration that 'possible' does not mean 'likely' or 'safe'. The girl was discharged from hospital on 14 June and died at home 5 days later. Better integration of medical expertise, earlier specialist child protection agency involvement, and clearer communication about the distinction between medical possibility and clinical likelihood might have prevented this death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsemergency medicineoral and maxillofacial surgeryradiology

Error types

systemcommunicationdiagnosticdelay

Clinical conditions

suspected child abusefacial injuriesbruisingnasal fracturesubgaleal haematomaperiorbital haematomapneumonia

Procedures

X-rayCT scanskeletal surveyclinical photographySCAN protocol

Contributing factors

  • Failure to route first hospital notification to specialist child protection response team (JIRT) on 8 June 2018
  • Technical error in ChildStory system routing second report to Maitland CSC instead of JIRT on 13-14 June 2018
  • Acting triage manager decision to conduct local enquiries rather than immediately refer second report to specialist joint investigation team on 14 June 2018
  • Delayed referral to JIRT until 15 June 2018 afternoon (27-36 hours after second hospital presentation)
  • Confusion between medical 'possibility' and clinical 'likelihood' of injury mechanism
  • Over-reliance on single maxillo-facial specialist opinion that mechanism was 'bizarre but possible' without adequate challenging
  • Passive acceptance by child protection staff of hospital opinions without proactive clarification of contradictions
  • Hospital discharge on 14 June 2018 despite request from child protection services to retain child overnight for further assessment
  • Hospital failure to use best endeavours to comply with child protection agency request to keep child in hospital
  • No home visit by JIRT before fatal event despite acceptance of case on 15 June; allocation message failed to reach coordinating agency on 18 June
  • Lack of coordination between agencies during critical weekend period (14-18 June)
  • Inconsistent accounts by caregivers not adequately prioritised as safeguarding concern

Coroner's recommendations

  1. Review and revise guidelines for JIRT referral criteria to ensure physical abuse presentations are immediately escalated to specialist joint investigation response teams
  2. Implement permanent ChildStory solution to identify and correct reports routed to wrong business unit
  3. Provide training for FaCS staff on physical injuries assessment and confidence to prioritise face-to-face assessment despite medical uncertainty
  4. Develop workshop for managers on 'stepping into authority' and appropriately challenging decisions not in children's interests
  5. Training for all staff on importance of likelihood versus possibility in medical injury assessment
  6. Formalise escalation procedures between health services and child protection agencies regarding safety admissions and conflicting opinions
  7. Establish 'Hunter New England Violence, Abuse and Neglect and DCJ and JCPRP Executive Collaborative' with regular tri-agency meetings including health, police and child protection
  8. Develop communication strategy addressing the meaning and use of terms such as 'possible' and 'likely' in non-accidental injury reporting
  9. Establish on-call response forms to provide JCPRP staff advance warning of incoming referrals from Helpline
  10. Implement formal minute-taking processes in multi-agency case conferences with accurate real-time documentation
  11. Assign key person/central contact in Child Protection Team upon receipt of referral with clear documented handover processes
  12. Improve consistency in day rostering of child protection consultant paediatricians
  13. Review and update Domestic Violence Kit advice about working with offending and non-offending parents
Full text
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