Finding into death of Baby A

1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine

A 22-month-old boy died from global cerebral ischaemic injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine exposure. He had multiple healing traumatic injuries (rib fractures, wrist fracture, mesenteric injury, scrotal bruising) consistent with non-accidental trauma that occurred 3-12 weeks before death, likely inflicted by his mother's partner. Critical clinical lessons include: incomplete family violence information sharing to Child Protection delayed appropriate risk assessment; hospital clinicians did not have access to family violence or forensic history; inter-agency information gaps prevented recognition of cumulative risk; methylamphetamine exposure in an infant is significant regardless of concentration and poses cardiac and neurological risks; and apparent lack of pain manifestation despite serious injuries may have masked abuse. Earlier identification of the partner's family violence history and drug use, combined with improved information sharing between police, child protection, and health services, may have altered outcomes.