Finding into death of Baby A

Contributing factors

• Neonatal abstinence syndrome from maternal methadone exposure
• Poor weight gain despite supplemental feeding regime
• Continued signs of opioid withdrawal
• Lack of dedicated overnight maternal support
• Inadequate multi-agency discharge planning
• Failure to notify Child Protection
• Absence of communication between hospital and correctional facility
• Vulnerable newborn discharged to unsupported mother in prison
• Mother's exhaustion and sleep deprivation
• Potentially unsafe sleeping environment
• Strict feeding plan without structural support to ensure compliance

Coroner's recommendations

1. Implement a multi-disciplinary approach to discharge throughout Victorian hospitals, akin to New South Wales practice, whereby if any healthcare practitioner holds concerns about discharge of a baby having particular regard to the environment into which they will be discharged, the baby is not to be discharged
2. Any child living in a prison ought to be regarded as being in custody for the purposes of critical incidents and deaths
3. Children who reside in a correctional facility with their parent or guardian ought to have improved access to healthcare; recommend that DPFC consider having an attending neonatologist or midwife on-site every day whenever they have infants residing there