Finding into death of Lily Grace Arbuckle
Deceased
Lily Grace Arbuckle
Demographics
0y, female
Date of death
2021-07-11
Finding date
2024-01-18
Cause of death
Head injury
AI-generated summary
Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and anxiety, experiencing suicidal ideation and fixated concerns about harming her baby. Maternal and Child Health services assessed her twice with EPDS scores of 11 and 14 but failed to follow protocol requiring investigation of self-harm questions and referral to Enhanced MCH services. The lactation consultant had no formal mental health training despite observing concerning statements. Critical failures included: inadequate escalation of mental health risk despite documented depression screening results, no proactive safety assessment regarding infant harm, insufficient engagement of the secondary carer (father) in postpartum mental health support, and lack of follow-up when mother could not be contacted days before the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Undiagnosed and untreated postnatal depression and anxiety in mother
- Failure by MCH services to escalate mental health risk despite EPDS scores indicating moderate to severe depression
- Failure to investigate EPDS question 10 (self-harm ideation) and assess risk to infant safety
- Lack of formal mental health assessment training for lactation consultant
- Insufficient engagement of secondary carer (father) in postpartum mental health education and support
- No automatic supervisor alert system for concerning EPDS scores
- Inability to contact mother in critical period (6-8 July) without escalated response
- No standardised practices for proactively involving secondary carers in postpartum support
Coroner's recommendations
- International Board of Lactation Consultant Examiners review accreditation requirements to ensure lactation consultants have undertaken education including demonstrated understanding of postnatal mental health, identification of mental health risks, and appropriate referral pathways
- Victorian Department of Health - Maternal and Child Health Services introduce automatic supervisor alert process if primary caregiver scores 13 or above on EPDS to ensure risk management plan is in place
- Victorian Department of Health - Maternal and Child Health Services provide regular staff training on requirement to query infant safety following EPDS question 10, supported by inclusion in clinical supervision
- Victorian Department of Health - Maternal and Child Health Services require engagement with secondary carers on at least one occasion in prenatal period to provide education on signs and symptoms of postnatal depression, anxiety and psychosis and support options (with primary carer permission)
- Victorian Department of Health - Maternal and Child Health Services introduce additional consultation in Key ages and stages framework requiring proactive engagement with secondary carer for education on postnatal mental health risks and support (with primary carer permission)
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