Inquest into the death of Baby G

Contributing factors

• failure to offer NIPT testing during pregnancy
• failure to detect Trisomy 21 prenatally
• failure of Territory Families to conduct thorough investigation into child protection notifications
• failure to identify and acknowledge family strengths
• failure to provide family support services despite policy requirements
• failure to refer to Down Syndrome Association peer support
• failure to secure appropriate housing for family
• failure to progress alcohol and other drugs rehabilitation referrals
• failure to conduct genuine safety planning with parents
• inappropriate and traumatic enactment of Provisional Protection with direction to leave hospital
• parents' emerging alcohol use in response to stress and isolation from community supports
• parental isolation from family and community supports
• inadequate accommodation and respite care planning
• severe pulmonary hypertension
• severe chronic lung disease
• recurrent respiratory infections
• feeding difficulties
• COVID-19 infection during hospitalisation

Coroner's recommendations

1. NT Health promote the Australian Pregnancy Care Guidelines with all health practitioners
2. NT Health, in consultation with Miwatj and other appropriate Aboriginal health care providers, consider how and in what circumstances NIPT testing can be made freely available to pregnant women, particularly those in remote locations, and make all reasonable endeavours to secure funding for and facilitation of the provision of free NIPTs where identified as appropriate
3. NT Health and Territory Families work together with the Down Syndrome Association (NT) to ensure that staff working with children are aware of the available services and referral pathways to that Association
4. The Attorney-General consider a reform of the Care and Protection of Children Act 2007 (NT) to include the principle of 'active efforts' similarly to NSW provisions