Victorian Coroner criticises health carers over baby death

19 April 2016
Moreland Council maternal and child health nurses failed to appreciate the significance of unexplained bruising on twin baby girls who were being physically abused by their mother, a Victorian Coroner has found.

Although one nurse noticed bruising on the sisters’ faces at their four-week check-up, she noted the injuries in the maternal and child health service’s electronic notes, but not in the babies’ “Green Book”, a health and development record that all Victorian parents receive following the birth of a child that is taken to all medical appointments and documents all of their milestones, health, growth, development and immunisation throughout their childhood.

While another maternal and child health nurse examining the girls four weeks later noticed unexplained bruising on one of the twins, which she noted in the baby’s Green Book and referred to the family’s GP for further investigation, she failed to review the twins’ electronic medical records, which would have raised concerns given similar unexplained injuries had been detected weeks earlier.

Less than two days after the eight-week examination in April 2012, one of the twins suffered a fatal brain haemorrhage and was found to have multiple skull, rib and other fractures. Similar injuries were found to have been sustained by her sister, who as a consequence, now has severe and permanent cerebral palsy.

The girls’ mother claims she was suffering from post-natal depression when she caused the injuries by repeatedly shaking and squeezing the babies while trying to settle them. She pleaded guilty to infanticide and one charge of recklessly causing serious injury and was convicted and sentenced in early 2014 to a community corrections order.

As the twin’s death was unexpected, violent and the direct result of injury, the Victorian Coroner was required to investigate the circumstances.

Coroner Ian Gray suppressed the identities of the deceased twin and anything that may tend to identify her, including her parents and siblings’ names on the basis that “disclosure would be contrary to public interest”. 

In handing down his findings following a lengthy inquest, Judge Gray has criticised the treating maternal and child health nurses for not responding appropriately to what were highly unusual injuries in non-mobile infants.

He has also ruled that the nurses should have been more rigorous in their exploration of the origins of the bruises, and they should have been more proactive in arranging for the cause of the injuries to be investigated.

The Coroner was also critical of the health care nurse who failed to read the twins’ electronic medical histories ahead of their eight-week examination. Had she have read the notes, he ruled, a “red flag” would have been raised given it was the second presentation of the twins with unexplained bruises.    

The nurse’s decision not to make direct arrangements for the bruise to be urgently investigated was described by the Coroner as a “lost opportunity to detect the harm to which the twins were exposed, to protect them from further harm and to identify their underlying injuries”. 

The Coroner was also critical in his findings of the lack of information sharing between health professionals given their mother had shown signs of post-natal depression and reported to her GP that she was tired and struggling with parenting unsettled twins. But this information was also not passed on to other health professionals and the twins’ mother did not disclose it.

Judge Gray acknowledged that the Green Book, which many health professionals used to communicate with each other, was not intended for that purpose, therefore, recommended that a database be created to store all health records of infants and children passing through the maternal and child health system, which could be accessed in real time by anyone monitoring and treating them. This would provide all medical professionals with relevant information about each other’s observations and examinations about infants and children they are treating, and their mothers.   

“Each practitioner would almost certainly have benefitted from information from the others, about the bruising, mental health screens, diagnoses and treatment plan,” he said.

Tom Ballantyne, medical negligence lawyer at Maurice Blackburn, described the case as “tragic and has had an unimaginable impact on the twins’ family.

“The Coroner has identified some clear failings by staff at Moreland City Council that have contributed to the tragic outcomes. He has also identified some concerning gaps in the system with respect to the communication of information between different health providers,” he said.

“All of the expert witnesses called by the Coroner emphasised the significance of bruising in non-mobile infants as a potential ‘red flag’. It is concerning that none of the maternal health nurses took further action despite bruising being noted on a number of occasions.

“Staff in these roles need to be appropriately trained to recognise the signs of potential abuse because the risk is too great to let these cases fall through the gaps,” he said.

“It is also concerning that the current system does not seem to allow for critical information being shared amongst different health providers. This outcome could have been avoided if subsequent doctors had been aware of the history of bruising.”

Mr Ballantyne added that while the death of the twin was “devastating”, her sister has a permanent brain injury and will have lifetime care needs.

After reading the findings, the twins’ father stated:

“We accept and appreciate Judge Gray’s findings and recommendation that a better medical reporting system be put in place between all medical professionals to manage the care of infants.

“We also accept that the Department of Education and Training continue with the implementation of clear guidelines for maternal health care professionals to understand that non-mobile infants with bruising is a sign that these infants need child protection and that mandatory reporting to authorities should take place.

“It is an absolute tragedy that (my daughter) died at eight weeks of age, and her twin sister suffered horrific life-long injuries because multiple bruising they had sustained on more than one occasion was not reported. It is heartbreaking for our family to think that if action was taken by the Moreland City Council maternal nurses, these gorgeous girls would today be leading normal, happy lives.

“We hope the government immediately accepts these findings and recommendations and commits a time frame and appropriate funding to make sure this never ever happens again.”

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