Coronial
VIChospital

Finding into death of Kaleb Baylis-Clarke

Deceased

Kaleb Baylis-Clarke

Demographics

<1y, male

Date of death

2016-01-30

Finding date

2023-05-29

Cause of death

Head injury in the setting of chronic subdural haemorrhage

AI-generated summary

Kaleb Baylis-Clarke, a 17-week-old infant, presented to hospital on 14 January 2016 with a head lump, vomiting, raised fontanelle and reduced milk intake. Cranial ultrasound showed fluid in subdural spaces. MRI on 15 January showed benign bilateral subdural hygromas and ventricular dilatation with no acute bleed. The neurosurgical team planned a fontanelle tap for 17 January but cancelled it when Kaleb clinically improved, appearing well with cessation of vomiting and tolerating feeds. He was discharged home. On 23 January, while in the care of his mother's partner Mr Vinaccia, Kaleb suffered cardiorespiratory arrest. Imaging revealed new bilateral subdural haematomas, retinal haemorrhages and extensive hypoxic brain injury consistent with abusive head trauma from acceleration-deceleration forces. Kaleb died on 30 January. The coroner found no obvious missed opportunities in medical care; the decision to cancel the invasive fontanelle tap was clinically reasonable given clinical improvement, and the tap cannot diagnose non-accidental injury. However, systemic improvements were recommended regarding early discussion of non-accidental injury concerns and liaison with forensic paediatric services.

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

Specialties

paediatricsneurosurgeryintensive careemergency medicineforensic medicine

Error types

system

Clinical conditions

subdural haemorrhagesubdural hygromaretinal haemorrhageshypoxic ischaemic brain injuryencephalopathysubarachnoid haemorrhageventricular dilatationcardiorespiratory arrestabusive head trauma

Procedures

cranial ultrasoundMRI brain scanCT brain scanfontanelle tap (planned but cancelled)cardiopulmonary resuscitation

Contributing factors

  • Non-accidental head trauma from acceleration-deceleration and rotational forces
  • Abusive head trauma (shaking with or without impact)
  • Family violence by step-parent
  • Lack of supervision by biological parent
  • Social factors: blended family with recently cohabiting step-parent

Coroner's recommendations

  1. Re-education of clinical staff regarding comprehensive examinations including review of previous admissions, documentation and diagnostics
  2. Further education of staff in Children's and Emergency Programs regarding early discussion and escalation when non-accidental injury is considered
  3. Implementation of procedure requiring discussion with senior doctor in Emergency Department for any child under 6 months with bruising
  4. Requirement to discuss with admitting consultant and document in EMR any child where possibility of non-accidental injury exists
  5. Mandatory discussion with Victorian Forensic Paediatric Medical Services (VFPMS) for any child where non-accidental injury is possible, with admission under general paediatrics for further investigation highly recommended
  6. Radiology reports identifying subdural collections in infants under 12 months must include advice to discuss with VFPMS
  7. Implementation of Electronic Medical Record (EMR) for improved communication across sites, departments and units
  8. Better integration of VFPMS within Monash Children's Hospital
  9. Enhanced education including 'The Child at Risk' Learning module from Department of Health and Human Services for all Emergency Program and Children's Program staff
  10. Establishment of Vulnerable Children Committee within Children's Program
  11. Implementation of Victorian Child Safe Standards across health services
  12. Further development of national minimum filicide dataset through collaboration between ANROWS and the Australia Domestic and Family Violence Death Review Network
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