Finding into death of Baby W

Contributing factors

• maternal amphetamine use throughout pregnancy
• intrauterine growth restriction
• absent or minimal antenatal care until 20 December 2013 (3 weeks before delivery)
• lack of early risk assessment for substance use
• no referral to specialist pregnancy addiction medicine service
• poor compliance with antenatal appointments without assertive follow-up
• inadequate information-sharing between child protection and maternity services
• punitive urine drug screening approach rather than supportive engagement
• absence of outreach services when mother disengaged
• meconium aspiration at delivery

Coroner's recommendations

1. Safer Care Victoria Maternity and Newborn Clinical network to replicate 'Substance Use during Pregnancy' information from neonatal handbook into electronic Maternity handbook, emphasising assertive follow-up by primary care providers including checking on referrals and managing non-attendance
2. Victorian Department of Health and Human Services to articulate referral pathways to home visitor services or outreach workers for follow-up with pregnant women failing to attend pregnancy care
3. Victorian Department of Health and Human Services to undertake research to establish current rate and timing of risk screening for substance use by pregnant women
4. Victorian Department of Health and Human Services to support maternity services in educating staff on appropriate framing of substance use risk enquiry questions and response to disclosure
5. Victorian Department of Health and Human Services to review opportunities to improve early intervention by outreach services for pregnant women using substances
6. Royal Australian College of General Practitioners to develop a RACGP website link to 'Substance Use during Pregnancy' information