Coroner demands change after Baby A dies in Victorian jail

A coroner has demanded change at Victorian hospitals after a 12-day-old baby girl died in a women’s prison less than a day after she was discharged from a Melbourne hospital.

Baby A was only 12 days old when she died at Dame Phyllis Frost Centre in Ravenhall. Picture: Kylie Else

A coroner has demanded Victorian hospitals change their procedures to prevent sick newborns from being discharged too early after a methadone-addicted baby died in a women’s prison.

Baby A was just 12 days old when she lost her life in August 2018 at the Dame Phyllis Frost Centre where her mum had been remanded in custody.

The little girl, who was withdrawing from methadone because her mum was prescribed medication to treat her drug addiction, was found lifeless in her cot with blue lips.

She had been discharged from hospital by her doctor only 18 hours earlier.

CPR was performed on Baby A after her mum made the terrifying discovery and screamed for help, but she was pronounced dead at the prison.

Baby A’s mum was remanded in custody at the Dame Phyllis Frost Centre on drug-related charges. Picture: Kylie Else

Her “devoted” mum was a member of the centre’s mothers and children program, which allows babies to live with their jailed mums if it is in the child’s “best interests”.

Coroner John Olle on Wednesday handed down his findings into the baby’s death after a 10-day inquest was held in September last year.

The court heard Baby A stayed at Sunshine Hospital in a special care nursery for eight days after her birth to be treated for jaundice and monitored for signs of methadone withdrawal.

But the bub was discharged eight days later despite continuing to lose weight.

A midwife visited the prison the next day to conduct a check, with Baby A immediately re-admitted to hospital due to further weight loss.

Three days later, despite still showing signs of opioid withdrawal and weighing less than when she was born, Baby A was once again discharged.

Experts called to give evidence at the inquest disagreed as to whether the infant was medically fit to leave the hospital.

Baby A’s cause of death was classified as sudden infant death syndrome (SIDS), otherwise defined as death due to natural causes.

Baby A was born in Sunshine Hospital. Picture: Ian Currie

Coroner Olle was critical of “systematic failings” which led to “sub-optimal” decisions being made in respect of Baby A, but was unable to find that her death was preventable.

“Even if Baby A had not been discharged, there was still the possibility that she may have died of SIDS,” he said.

But the court heard pediatric nurses at Sunshine Hospital, who cared for Baby A alongside neonatologists and paediatricians, raised concerns about whether she was ready to be discharged.

In September, an expert told the inquest that in New South Wales if any member of a vulnerable baby’s medical team opposed discharge, then the child would not be sent home.

However, it was the practice at Sunshine Hospital that the relevant neonatologist had the ultimate decision regarding discharge.

Coroner Olle recommended the health department follow New South Wales’ lead and implement a “multidisciplinary approach to discharge throughout hospitals in Victoria”.

This means if any member of a medical team holds concerns about the discharge of a baby, the child is not to be released.

“The key learning before me is that multidisciplinary approaches for vulnerable children is essential,” he said.

“This is the only approach that will best guarantee that vulnerable children will never be placed at risk due to miscommunication and misunderstandings.”

The case comes as Australian women and newborns are being discharged from hospital in record time after childbirth.

Baby A’s mum was a member of the centre’s mothers and children program, which allows babies to live with their jailed mums. Picture: Tony Gough

Coroner Olle said it appeared the decision to discharge Baby A was influenced by a belief there would be support for the mum in the prison.

However, unbeknown to the medical team, the first-time mum would be alone and unsupported during the night upon her return to jail.

“It is my view that she likely never would have been discharged … as other medical professionals within the hospital would have investigated the circumstances into which Baby A would be discharged and it would have been self-evident that Baby A did not have the necessary supports for safe discharge,” he said.

He added the failure to ensure Baby A’s mum had 24-hour dedicated maternal support after the “cherished” bub was discharged from hospital was one of the most significant omissions he identified.

“In all the circumstances, Baby A’s mother was the embodiment of a first-time mother, whose capacity to meet the challenges of a vulnerable baby demanded dedicated maternal support,” he said.

He also recommended the state government consider having a neonatologist or midwife attend a correctional facility every day if there are infants residing there.

“Whilst healthcare is an important and fundamental right of any prisoner, children – and especially vulnerable children – require access to healthcare outside of the structure ordinarily available to prisoners,” he said.

The Coroners Court gave the baby a pseudonym to “protect the privacy of the parents”.