Inquest into the death of Baby J

Contributing factors

• failure of attending obstetrician to provide direction or attend to live-born infant
• lack of protocols for management of live births following termination
• failure to alert nursing staff of possibility of live birth
• absence of medical practitioner presence or guidance at delivery
• failure to assess infant for gestational age and viability
• responsibility vacuum created by doctor's refusal to acknowledge duty of care to born infant
• inadequate documentation and consultation notes
• unavailability of supervisory nursing support

Coroner's recommendations

1. Protocols be put in place in the Northern Territory (by statute, regulation or otherwise) to ensure that children who survive termination procedures are, at the very least, immediately assessed for gestational age and viability by a medical practitioner. Ideally by a paediatrician, but if not possible, the doctor who performs or initiates the termination should assess and document their assessment. If that doctor is not present at birth, those in charge of the baby should make arrangements for urgent medical assessment.
2. The management and staff of all hospitals and clinics – public and private – in the Northern Territory and medical practitioners generally should be made aware of their legal obligations towards any children who survive termination procedures, including the obligation to report deaths of such children to the Coroner.
3. The protocols should apply to all hospitals and clinics – public and private – in the Northern Territory.