Inquest into the Death of Baby H (Name Subject to Suppression Order)

Contributing factors

• lack of access to complete child health records by emergency department
• lack of awareness by treating physicians of prior bruising observations
• ineffective communication between child health services and emergency department
• failure by child protection department to notify hospital of referral context
• inappropriate contact details provided to notifier (grandmother)
• absence of team leader during critical case management period
• prolonged interim safety plan extending beyond appropriate duration
• safety plan placing excessive responsibility on single individual (grandmother)
• failure of grandmother to reach department on 20 May 2017 when new concerns emerged
• delayed child protection worker allocation
• delay in convening safety meeting with expanded network

Coroner's recommendations

1. Western Australian Government should conduct a regulatory impact review and consider amending the Children and Community Services Act 2004 (WA) to include a duty to report any injuries in non-ambulant children, similar to existing mandatory reporting requirements for child sexual abuse, and extend associated training programs to cover this new reporting duty
2. Department of Communities should include information regarding appropriate contact details for staff (including after-hours) in its High Risk Infant Policy, with private mobile phone numbers only provided in exceptional circumstances
3. Department of Communities should prepare a policy document setting out practices and procedures for contact with family members following the death of a child in the Department's care, including options for counselling support and communication of systemic improvements made in response to the child's death