Finding into death of Siya Yogin Patel

Contributing factors

• insufficient breastfeeding and inadequate milk supply
• Medicare ineligibility creating financial barriers to postpartum care
• failure to act on 11% weight loss at GP visit
• lack of face-to-face maternal and child health assessment
• telephone-only telehealth consultation without physical examination
• failure to identify vulnerable family (first-time parents, recent emigrants, limited support)
• lack of communication between hospital discharge, GP clinic, and MCH services
• inadequate clinical processes at GP clinic for neonatal assessments
• COVID-19 related service delivery restrictions and workforce shortages
• absence of weight check at MCH enrolment visit
• lack of enhanced care referral for vulnerable infant
• absence of domiciliary midwifery follow-up

Coroner's recommendations

1. That the Minister for Health and Aged Care make an Order pursuant to subsection 6(1) of the Health Insurance Act 1973 (Cth) to declare that babies born in Australia shall be treated as eligible persons for Medicare purposes regardless of parental eligibility
2. That Mercy Health provide a hard copy of the discharge summary to new parents at discharge to include in the My Health Learning and Development book (Green Book)