Cries for help ignored before tragic deaths of baby, mum

A coroner has called for a major overhaul to child and maternal health services after a desperately unwell mother’s pleas for help went unanswered in the days before she killed her baby.

Melissa Arbuckle tragically took her own life last year.

A Coroner has called for reform to Victoria’s maternal and child health services after finding insufficiencies in the lead up to the killing of a nine-week-old baby by her desperately unwell mother.

Melissa Arbuckle was suffering from severe post-partum depression and possible psychosis when she laid her daughter Lily on the train tracks near Upwey station in July 2021.

Lily died of head injuries while Ms Arbuckle survived the collision but ended her life last January.

State Coroner Judge John Cain’s investigation into Lily’s death found key medical staff failed to appropriately respond to her mother’s cries for help.

Melissa Arbuckle, a former vet, was suffering from severe post-partum depression following the birth of her little girl. Picture: Supplied

Court documents reveal maternal child health nurses at Yarra Ranges Shire did not make necessary inquiries about whether Ms Arbuckle had thoughts of harming Lily after she returned a high score on a depressing screening tool for post-natal women.

Her score of 14 on the Edinburgh Postnatal Depression Scale (EPDS) indicated she was suffering major depression and warranted a series of interventions including referrals to a doctor and the centre’s Enhanced Maternal Child Health program – but none of this occurred.

“Melissa was not queried in relation to the risk she posed to Lily and was not engaged with Enhanced MCH services or additional supports,” Judge Cain said.

“I am particularly concerned given that this was the second time that Melissa had made reference to experiencing difficulties with her mental health and wellbeing and had made comments, at an unknown date, to suggest that further inquiry regarding her risk to Lily was warranted.”

The court heard that nurses made five unsuccessful attempts to contact Ms Arbuckle by phone in the days before she killed her daughter.

Melissa Arbuckle had on numerous occasions spoken of her depression.

Prior to this Ms Arbuckle had on numerous occasions spoke of her depression and feeling that she was not coping.

The Yarra Ranges Shire’s nursing co-ordinator submitted to the Coroner’s Court of Victoria that had Ms Arbuckle been admitted to the Enhanced MCH program, the unanswered calls would have triggered an escalated response such as a Victoria Police welfare check.

Judge Cain recommended a suite of changes to the Department of Health Maternal and Child Health Services including that staff are trained on the need to query infant safety and automatically alert supervisors if a primary caregiver scores 13 or above on the EPDS.

His Honour also recommended secondary carers such as dads are engaged by nurses at least once before the arrival of a baby to educate them on the signs of post-natal depression, anxiety and psychosis.

It was also recommended that lactation consultants undergo training on mental health risks in post-natal woman and making referrals for appropriate supports.

A Department of Health spokesperson said the recommendations were under consideration.

“We are taking the appropriate time to consider them,” the spokesperson said.

Ms Arbuckle pleaded guilty to infanticide and was spared jail and sentenced to a three-year good behaviour bond in April 2022.