Finding into death of AA (Baby D)

0y · Female·head injuries

Twin infant died of head injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weight gain. The case reveals critical clinical failures: bruising observed on both immobile twins at the four-week assessment was not appropriately investigated; at the eight-week assessment, bruising on one twin was noted but without awareness of the previous finding; maternal depression screening tools showed significant abnormality but were not acted upon with sufficient urgency. No health professional identified risk of harm to infants. The coroner found that earlier investigation of unexplained bruising on immobile infants—a rare red flag—could have led to skeletal surveys, detection of underlying injuries, and protective intervention before the fatal episode two days later.