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

Contributing factors

• violent shaking by adult on multiple occasions
• failure to escalate concerns after identification of sentinel bruise on 6 May 2019
• failure to ensure medical assessment despite child health nurse referral to hospital
• inadequate safety planning prior to discharge from neonatal unit
• failure to take action following attempted termination in December 2018
• inadequate response to concerns about family violence and domestic abuse
• failure to address uninhabitable home environment with no running water or electricity
• inadequate supervision of mother under extreme stress with no support network
• social isolation of mother
• possible parental drug use (methamphetamine and cannabis)

Coroner's recommendations

1. Implementation of the early childhood injury pro forma currently used at PCH ED throughout all emergency departments in WA treating children, subject to satisfactory results of prospective study
2. Embedding the TEN-4-FACESp decision rule as a screening tool for suspicious bruising in children under five in the Department of Communities Case Practice Manual, with automatic consultation with consultant paediatrician or PCH CPU when suspicion is raised
3. Child health nurses should be encouraged to contact PCH CPU when concerns are not adequately addressed by Communities
4. Consideration of mandatory reporting of physical abuse in Western Australia (in addition to existing sexual abuse requirements) to align with other states and improve identification and reporting of suspicious injuries
5. Improved communication and collaboration between Department of Communities and experienced health professionals including hospital social workers, child health nurses and Child Protection Unit staff at PCH
6. Practical emphasis on good communication and different expertise perspectives between Communities workers and healthcare professionals regarding what constitutes normal safe home environments and concerning injuries in young children
7. Implementation of High Risk Infant practice guidance with appropriate staff training across all regions
8. Continued development of Safe and Together model for improved responses to family violence
9. Review of policy and training related to pre-birth safety planning when parents have documented history of family violence, neglect and mental health concerns