Finding into death of EGB
Deceased
EGB
Demographics
<1y, male
Date of death
2021-08-31
Finding date
2026-09-09
Cause of death
Head injuries
AI-generated summary
An 8-week-old boy died from head injuries caused by non-accidental trauma inflicted by his father, who admitted to shaking the infant in frustration during nighttime feeding. The coronial investigation identified multiple missed opportunities by healthcare providers across four presentations over the child's final eight weeks. Clinicians failed to recognise signs of inflicted trauma including facial abrasions, genital bruising, multiple rib fractures at different healing stages, and frenulum laceration. Chest x-rays were twice misreported as normal when bilateral rib fractures were visible. Contributing factors included cognitive bias among clinicians, inadequate specialist training in child abuse recognition, failure to conduct thorough examinations, and absence of shared electronic medical records between services. The coroner found that earlier identification and escalation of concerns to child protection may have prevented death. Recommendations focus on statewide electronic medical records implementation and embedding inflicted trauma screening tools in emergency departments for all infants under 12 months.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Non-accidental trauma including shaking inflicted by father
- Multiple blunt force impacts over preceding weeks
- Failure to recognise signs of inflicted trauma
- Cognitive bias and false reassurance by family without typical socioeconomic risk factors
- Inadequate specialist training in child abuse recognition
- Failure to conduct thorough top-to-toe physical examinations
- Misreporting of chest x-rays as normal when fractures were visible
- Absence of shared electronic medical records between health services
- Parental stress, HVR's fatigue and frustration with feeding difficulties
- COVID-19 related isolation limiting family support and healthcare resources
Coroner's recommendations
- Safer Care Victoria work with Royal Children's Hospital to create statewide guidance using EMR functionality to identify potential risk of inflicted trauma in infants under 12 months and trigger appropriate response
- Department of Health conduct feasibility study to determine whether a statewide electronic medical record system can be implemented and provide implementation roadmap
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Source and disclaimer
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