Inquest into the Death of Baby Z

Contributing factors

• possible co-sleeping with mother
• possible cerebral subcortical nodular heterotopia in right frontal lobe with uncertain relationship to seizure
• presence of desmethyldiazepam and methadone in baby's system (transferred via breast milk)
• maternal drowsiness and reduced responsiveness to infant needs
• inadequate inter-agency communication regarding maternal concerns prior to discharge from hospital

Coroner's recommendations

1. KEMH to implement discharge planning meeting requirement when discharging babies to Bandyup or Boronia prisons, including social worker, Ngala worker, Family Links Officer, midwifery manager, and mother
2. Integration of social work notes within medical file at KEMH (rather than separate storage) to improve information flow
3. Mandatory safe-sleeping e-learning module for all KEMH social workers at commencement
4. Training by SIDS Foundation for KEMH staff regarding risks of co-sleeping
5. Social workers to document co-sleeping concerns in medical notes and escalate to DCP if behaviour persists
6. Implementation of new guideline SW5 Obstetrics Patients Protocol for patients in custody
7. Regular supervision of social workers at KEMH, particularly for DCP-involved cases
8. Development of system to account for residential children in prison during musters and cell checks
9. Implementation of night-time cell checks that actively require sighting of baby in cot (now in place at Bandyup)
10. Laminated cards at cell viewing hatches to indicate which prisoners have resident children
11. Registration of residential children on prison information system (TOMS)
12. Clarification of prison health staff duty of care to residential children to ensure medical attention is provided when children become unwell
13. Increased documentation of mothercrafting assessments by midwives during shifts
14. Implementation of postnatal discharge protocol for patients readmitted shortly after initial discharge