Finding into death of Lily Grace Arbuckle

0y · Female·Head injury

Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and anxiety, experiencing suicidal ideation and fixated concerns about harming her baby. Maternal and Child Health services assessed her twice with EPDS scores of 11 and 14 but failed to follow protocol requiring investigation of self-harm questions and referral to Enhanced MCH services. The lactation consultant had no formal mental health training despite observing concerning statements. Critical failures included: inadequate escalation of mental health risk despite documented depression screening results, no proactive safety assessment regarding infant harm, insufficient engagement of the secondary carer (father) in postpartum mental health support, and lack of follow-up when mother could not be contacted days before the death.