Finding into death of Lily Grace Arbuckle

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

1. 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
2. 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
3. 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
4. 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)
5. 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)