Demographics
0y, female
Coroner
State Coroner Judge Ian L Gray
Date of death
2012-04-26
Finding date
2016-03-16
Cause of death
head injuries
AI-generated summary
Twin infant died of head injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weight gain. The case reveals critical clinical failures: bruising observed on both immobile twins at the four-week assessment was not appropriately investigated; at the eight-week assessment, bruising on one twin was noted but without awareness of the previous finding; maternal depression screening tools showed significant abnormality but were not acted upon with sufficient urgency. No health professional identified risk of harm to infants. The coroner found that earlier investigation of unexplained bruising on immobile infants—a rare red flag—could have led to skeletal surveys, detection of underlying injuries, and protective intervention before the fatal episode two days later.
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Specialties
Error types
IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: 2012 / 1474
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: AA
Delivered On: 16 March 2016
Delivered At: Coroners Court of Victoria 65 Kavanagh Street, Sotithbank
Hearing Dates: 27, 28, 29 and 30 October 2015 Findings of: JUDGE JAN L GRAY Representation: Ms Fiona Ellis, on behalf of The Royal Children’s Hospital
Ms Michelle Armstrong, on behalf of © MsA
Ms Teresa Porritt, on behalf of Department of Health and Human Services
Mr Micliael Regos, on behalf of Moreland City Council
Ms Erin Gardner, on behalf of Department of Education and Training
Mr Sebastian Reid, on behalf'of Dr Zagarella and Nurse Goodchild
My Paul Haley, on behalfof. MrA
Police Coronial Support Unit Senior Sergeant Jennette Brumby
Page | of 80
1, JUDGE IAN L GRAY, having investigated the death of AA AND having held an inquest in relation to this death on 27, 28, 29 and 30 October 2015 at Melbourne find that the identity of the deceased was AA born on 28 February 2012 and the death occurred 26 April 2012 at the Royal Children’s Hospital, Flemington Road, Parkville, Victoria, from: 1 (a) HEAD INJURIES
in the following circumstances:
Background
l. On 28 February 2012, MsA gave birth by caesarean section to two female non identical twins, AA and BA at the Royal Women’s Hospital.
Ms A and the’ father of the twins, Mr A and ihe three children all
lived together in the privately owned family home in Coburg,
bottle feed the twins from the outset,
Both Ms A and Mr A took time away {rom their respective employment and provided the primary and essentially exclusive, care for both AA andBA They were also heavily supported by Ms A's mother, Ms M who visited the family home almost daily. Ms M essentially maintained primary care of CA whilst at the home,
Ms A and “4 shared parental responsibilities for the twins by swapping each night
as their sole carer. The nominated parent would care for the twins exclusively during the night with assistance from the other parent during the day. The nominated parent would sleep on the
floor in the twins’ bedroom overnight. The twins slept together in a crib in their bedroom.
6 The paxent not responsible for the twins on any particular night would sleep in the master bedroom with CA vA CA was sotnewhat sheltered from the twins, with Ms A keeit to énstite that’ his routine
was not significantly disrupted by the arrival of the twin girls.
"Page 2 of 80
Both twins were irritable, experienced difficulty with sleeping and feeding and weré a challenge
io settle. They would also cry a lot.
CA by contrast, had been an easy baby. He was a happy child and easy to manage. He was regarded highly by Ms A Mea and Ms M
Timeline of Contact with Health Services
In the eight weeks following the twins’ birth, the family had a number of contacts with health service providers, It-is important fo set out the timeline of these appointments and consultations, which were the focus of my investigation into AA's death and consideration of whether or
how it might have been foreseen and prevented.
On 7 March 2012, Ms Roslyn Monagle (Ms Monagle), a Maternal and Child Health (MCR) nutse with the Moreland City Council Maternal and Child Health Service (Moreland MCH Service), contacted the family by phone. prior to attending for a planned home visit, She spoke to Ms A who advised that she was doing well, had lots of support and was very busy. “*4
, advised that the domiciliary service from the Royal Women’s Hospital were still visiting every two days and were also due to visit that day. She indicated that rather than have a home visit, she would be happy to come with the twins into the Moreland MCH service and a visit was
booked for the following week:
On 11 March 2012, both twins, now 12 days old, were taken to the Emergency Depariment of the Royal Children’s Hospital (RCH) by their parents because of their concerns about the twits’ increasingly unsettled behaviour after feeds, AA . was physically examined and a history was taken froin her parents. Boih twins were relerred to the RCH Unsettled Babies Clinic with the following notation: “escalating unsettledness post.feeds 1-2 hours. Gaining wt, feeding well,
no fever or other symptoms, ?colic.?"
On 15 March 2012, accompanied by their father, the twins, at sixteen days old, attended their firstassessmeni with the Moreland MCH Service.’ Ms A was reportedly unwell, or at least very tired, and remained at home to rest, The review was conducted by MCH nurse, Ms
Wa relayed that both twins had:been taken to the RCH a few days earlier
Monagle.
becatise. they were unsettled. According to the notes of the consultation, Mra reported thatthe ‘twins had beer seen by a paediatrician and diagnosed with “colic”. He advised that they were awailing a.review. appointment with a pasdiatrician‘at.the RCH, The twins were physically examined, weighed and -meastired and a possiblé hip breech was detected, with a hip scan
flagged for May, No other matters of concern ‘were recorded, No injuries. or bruising were
' Coronial Brief, p 1317
observed. Ms Monagle recalled that the twins were settled and content and that Mr A undressed and redressed them both competently. It was noted that he had two months off work
at this time.
were also fine.
is. On .30 March 2012, the twins attended their fowr week assessment with the Moreland MCH Service, Their review on this occasion was conductéd by MCH nurse, Ms Anne Kingston (Ms Kingston). The twins attended accompanied by their mother and brother. The twins were undressed, weighed, measured and physically examined. At this assessment, AA was observed to have a small bruise measuring 6mm on her right cheek. Her twin sister BA was observed to have four small bruises measuring approximately 4 mm in a cluster on her left cheek. Ms A was questioned about the origin of the bruises, to which she replied “J don’?
mow what they are doing, they must be bashing each other/bashing themselves with the colic, they are like Houdini, they get out of their wraps no matter how tight Iwrap them’? Ms A went on to explain that she placed the twins end to end in the cot for sleeping with their heads aligned, which explained how each twin’s fist was sufficiently proximate and alignéd with the others face. The safe placement of the babies was discussed and the possible need for future medical follow up and investigation if the twins proved to bruisé easily, The bruising was noted in the Moreland MCH Service electronic notes of each twin, but was not noted in their “Green Books”, a health and development record distributed to all Victorian parents following the birth of their child, and held by the parent. : ,
12 is borderline and- may or may not require referral to a general practitioner. Ms Kingston
2 Coronial Brief p 183 + Coronial Brief p 1532
17,
discussed Ms A *s mood with her and her available supports. Ms A reported that she was well supported by her husband and mother and that CA was coping well with his new sisters. Ms A was observed to be very upbeat with her management of the twins, She did disclose that she felt down sometimes because she couldn’t help the twins with their colie and she felt sotry for them. Ms A presented as a caring and competent parent and was observed to interact in an appropriate and affectionate manner with her children throughout the consult. She appeared physically well and reported that she had been well since the day the twins were born. In the circumstances, Ms Kingston reviewed with Ms A what she was doing to help and cornfort the twins. She also advised Ms A that.it was important to follow
up if she experienced any persistent low mood.
On 10 April 2012, the twins were seen by the family General Practitioner (GP), Dr Sam Zagarella at the Niddrie Medical Centre, Both parents, the twins and their brother attended the consultation. The focus of the appointment was management of the twins feeding and colic. A history was taken, (which included that the twins had been treated for colic at the RCH), the twins Were weighed and a brief physical examination was undertaken. Ii order to perform an abdominal examination, the twins’ jumpsuits were unfastened, but they were not otherwise undressed. The exantination revealed nothing of note and no injuries or bruises were observed.
Dr Zagarélla was not informed by cither parent about the facial bruises that had been observed on both twins al the Mofeland MCH Service consultation 11 days earlier. Dr Zagarella gave advice about different formula and anti-reflux medications that might: be-trialled. Although the appointment was for the twins, Dr Zagarella inquired about how Ms A was feeling, She reported that she was stressed, tired, and not sleeping well, Given her response, Dr Zagarella had MsA edinplete the K10* and Depression Anxiety Stress. Scales (DASS) seréening tools in order to ascertain if there were issues with her mental healih which might require follow up.
Her responses to specific questions revealed that she self-reported as. having poor attention, poor concentration, occasional confusion and a sense of worthlessness and hopelessness. She denied suicidal ideation, In view of her high scores on these screening tests, which are not diagnostic, a further appointment was made for Ms A to see Dr Zagarella and the practice’s mental health nurse on 18 April 2012, for a mental health assessment-and, if necessary, completion of a mental health plan, Notwithstanding the possible high levels of stress, anxiety and depression
suggested by the screening tools, in a clinical context, Dr Zagarella observed Ms A on 10
April 2012 to be rationale, loving, caring, engaged, warm and concemed for the wellbeing of her
children, He also noted that she was well supported by her family.>
On 18 April 2012, Ms A attended an appointment with her GP, Dr Zagarella and a mental health nurse, Ms Sally Goodchild (Ms Goodchild), Mr A accompanied Ms A to the Medical Centre but did not sit in on the consultation. A mental health review was conducted, primarily by Ms Goodchild. Ms A reported that she was struggling with parenting the unsettling twitis, Ms A was observed to be tired, but generally bright, calm and relaxed.
She interacted appropriately, demonstrating an ability to discuss her needs and make reasoned decisions. When asked, she denied that she was at risk of harming herself or her children. She reported that. she had good support with her husband and extended family providing assistance.
Ms A reported some improvement in thé twins’ level of irritability since the previous consult on 10 April 2012, and Dr Zagarella recailed some improvement. in-Ms A too, with her presentation judged to be a bil brighter and more positive. The possibility of a referral to the Tweedle Child and Family Health service (Tweedle) was discussed, to assist with strategies for parenting the unsettled twins, Ms A declined this, at least in part as a result of the fact that they were already secing the Unsettled Babies Clinic at the RCH, and had an appointment the next day. A referral to a psychologist specialising in women’s mental health was discussed.
This was also declined because the psychologist*s: rooms were located some distance from her heme. Ms A agreed instead to a referral to a psychologist operating from the same practice, An appointment was made for | May 2012, and a mental health plan was prepared accordingly, with a copy provided to Ms A When asked in general terms, Ms A
indicated that she did not want to commence any medications related to her mood at that stage.
Dr Zagarella considered this reasonable in all the circumstazces, and was content that jt was a
matter which could remain under review.’
On 19 April 2012, the twins were seen at the Unsettled Babies Clinic at the RCH Centre for Coimmunity Child Health. They attended the appointment with both parents and were seen by Dr Anne Dawson, who at that time was in the third year of her advanced training in General Paediatrics, Only one of the twins,BA in fact’had an appointment on that day. However, at the request of their parents, both twins were seen-together. Dr Dawson took a full history from the As encompassing antenatal, obstetric and postnatal history. Information was recorded about their feeding patterns, amount of formula tolerated, petiods and time of irritable
behaviour, voniiting, rashes, bowel patterns and strategies used (including medications) in
4 Inquest transcript p 548 § Inquest trangeript p 552
7 Inquest transcript p 564 — 565 and p 592 — 593
20,
21,
response to their irritability. Dr Dawson was not informed by either parent about the facial bruises that had been observed on both twins at the Moreland. MCH Service consultation 11 days earlier. The twins’ parents reported that they appeared to be improving over the previous 48 hours, In addition to taking a history, Dr Dawson conducted a full physical cxamination of AA which revealed nothing remarkable. No evidence of injwry or bruising was observed.
BA was not examined at this time as she was asleep. Having found no organic cause for the twins’ unsettled behaviour and in view of the history provided, Dr Dawson diagnosed colic and put in place a management plan to reflect this, which included providing the family with information about infant erying and response strategies, a diary to carefully record the twin’s patterns and behaviours and a timetable for withdrawing from some of the medications they had
commenced,
While at the clinic, Ms A completed another EPDS and provided this to Dr Dawson. Her score was 17, which is considered a positive screen for possible perinatal depression.* On question 10, which relates to thoughts of self-harm over the previous seven days, Ms A had ticked the box ‘hardly ever’, which is regarded asa positive answer, and cause for further inquiry.” Dr Dawson explored the resvilts of the EPDS with Ms A She ascertained what supports Ms A had in place, including that her husband was currently off work. and at home to assist with the twins, and thal they were alternating nights caring for the twins. Dr Dawson recorded that Ms A had seen 4 mental health nurse the previous day and had been referred loa psychologist by her GP. She asked Ms A if she had thoughts of harming herself or her children, to which she. replied “no”. Dr Dawson’s impression of the As
during the consultation was that they were well engaged with the (wins and appeared happy.
Before the conclusion of the consultation, and while the family waited, Dr Dawson discussed the matter with her supervisor Associate Professor Harriet Hiscock (A/Prof Hiscock). There was consensus on the management plan for the twins and that the supports that were already in place
for .MsA_ were appropriate at that time. A review appointment was made for 3 May 2012,
On 24 April 2012, the twins attended their eight week assessment with the Moreland MCH Service. They were accompanied by both parents and their brother and were seen by Ms Monagle. Both twins had recorded poor weight gain, BA _ in particular, and their parents reported that they had been vomiting and that they were: very concerned about their fussy feeding. Both parents were a little exasperated, or at least confused, because the twins had been
commenced on the medication Zantac and then they had ceased (his on the contrary advice of
8 Coronial Brief p.1533
BA's
the RCH. During this consultation, Ms Monagle observed a pea sized pale bluish bruise on the right-side of BA's face and-a small scratch also on her face. The As were questioned about this and were unable to explain how it had occurred. The possibility was discussed that CA may have caused the bruise and Ms Monagle discussed the need to carefully supervise him when around the twins, The possibility of a blood disorder was also discussed. Ms Monagle had not reviewed Ms Kingston’s notes of the twins* four week assessment and was thus unaware that bruises had been observed and documented on both the twins’ faces at that time. Ms Monagle tecorded the bruise in BA's . electronic Moreland MCH Service record and further noted it in her Green Book. Ms Motiagle conducted a full physical examination ofboth the twins and observed nothing further of note, and certainly no further evidence of injury, including bruising, She observed both Ms A and Mr A to be attentive, confident and gentle parents as they-each undressed.and redressed a twin for examination and to have appropriate attachment with them, She observed both twins to be quiet but alert and engaged. Ms Monagle was concerned that the As were tired and struggling and may require additional support to help them deal with the large workload of'three small children. Ms Monagle prepared a refetral letter for BA to the family GP. She noted in the letter the unexplained bruise she had observed, BA's poor weight gain and het fussy feeding. She provided the letter to the As so that they might give it to their.GP. She made atrangements with the family for a follow up visit the next week. Following the consultation she spoke to Nurse Joan Myers Braun of the Enhanced Maternal and Child Health Seivice (EMCH Service), with a view to exploring whether the EMCH Service might take on the family and provide them with some additional support, She was informed that although the EMCH Service was currently full, they would try to pick up the A Family as soon as possible and with some priority. Ms Monagle also discussed the possibility of a referral to Child First, Following this conversation, Ms Monagle resolved to conduct a home visit with the family later in the week in otder to secure their agreement to a make referral to the EMCH Service and to Child First, and to formally
commence that process,
Circumstances of fatal event
22,
On.25 April 2012, Mr A was the nominated parent to care for the twitis.overnight. He fed theni at-8.00pm and placed them into their crib, He then went to sleep on the floor. Ms A
was in the master bedroom with CA At approximately 11.30pm, Mr A fed the twins again, AA was somewhat unsettled after this feed.and at approximately 2am on 26 April 2012, Mr A became aware of AA making noises which sounded distressed and
seemed to be getting louder. He observed her to be Jimp and pale and shorily thereafler, while
he was holding her, she stopped breathing.
Mr A then called oulto MsA told her thatAA ~ had stopped breathing and asked her to ring an ambulance. Ms A rang her mother, Ms M ,, and asked her te come to their house. She then made a phone call to “000”, During the phone call Ms A relayed information to Mr A who was performing cardio pulmonary resuscitation (CPR) on instruction from the call-taker. Ambulance paramedics arrived ‘at the house at approximately 2..lam. They found AA with pulseless electrical activity and not breathing. She was intubated with restoration of circulation following adrenaline adniinistration, and conveyed to
the RCH.
At the RCH, AA was extensively examined by attending medical staff, who found evidence of both old and new bleeding in the brain and multiple skull fractures. AA was intended for émergency surgery however was unable to be stabilised long enough for this to proceed. She
died on the opérating table at 7.55am on 26 April 2012.
The injuries suffered by AA were considered 10 have likely been caused by non-accidental trauma. Doctors questioned both Ms A and Mr A as to how these injuries could have
occurred, Neither parent was able to provide an explanation.
In the cireunistanices, the Homicide Squad were notified of the death of AA and attended at the RCH, Both parents were interviewed under caution, AA siblings, CA and BA were taken that day to the Victorian Foreristc Paediatric Medical Service (VEPMS), also at the RCH, and examined. CA's examination revealed no evidence of recent injury. BA's examination revealed injuries similar to those which had been sustained by her sister, including multiple skull fractures, multiple intracranial haemorrhages of differing ages, softening or loss of brain tissue, multiple rib fractures, fracture of the left clavicle, possible fracture of left radius and possible injury to-her tibial shaft. Bruising was also observed on BA's right forehead, left leg, and.labia. BA‘s cornplex constellation of injuries indicated that she had been subject to hon-accidental trauma.
During her police interview on 26 April 2012, Ms A was questioned:extensively about her inothering of the twins. She was confronted with the extent of the injuries to both girls. She
initially stated that she did not cause the injuries.
Fyom the outset she spoke of the colic that the girls suffered, of their unsettled behaviour-and of
the problems she and her husband had gétting them to sleep. She acknowledged that neither
twin was putting on as much weight as they should have and that this was the case at sight
‘Page 9 of 80
29,
weeks of age. She described her routines with the twins and emphasised the apparent pain the twins were in and that they would wake up screaming, She put it that “colic just doesn’t go away.” She did acknowledge however that children do grow out of colic. She spoke of the various visits to medical practitioners, including Dr Zagarella. She was adamant that the babies
had never fallen off anything and that their injuries could not have been caused in that way.
Throughout the first part of interview, she was insistent for a lengthy period that she couldn't explain the injuries. She was consistently emphatic that her husband could not and would not
have caused them, Ata later point in the interview she asserted that she did have postsiatal depression,"!
In the context of post natal depression she was asked if she took out any frustration on.the babies and said “They were just crying all the time, 1 just didn't feel worthy of being a mother because I couldn't help them.” She said she “Just cuddled them”? Then said “.,.and rocked them and rocked them and rocked them and rocked them and rocked them and rocked them.”'* She was then asked if she ever got angry with them, she said that she screamed a bit and in relation to whether she grabbed “them extra hard’! or something similar, said that she didn’t think so and that had that happened it would have been accidental. She then conceded that in the context of her post natal depression and her frustration, she was “constant rocking all the time with them.”'® She went on to say that “7 mean now I’m worried about this postnatal depression if it
made me flip...°""
Further on in the interview, after being told how the hospital (RCH) staff were describing the various injuries to the twins, she was asked questions about the fact that given the arrangements with the children, the only persons who could have caused them were her and her husband, In that context she said “Zhe only. thing I can think of is what if when I was thai lew that I just Slipped and I don’t even know that I flipped. Is that a possibility?”'® She went on to say “They're always crying, they're always eryirg, you know, like, it's almost like — and then we rocked them and then we rocked and that's all I could do for them."\° She referred to her own
depression and the fact that she was awaiting an appointment to see a psychologist, she said that
'° Coronial Brief - Transcript of video recorded interview with Ms A 26 April 2012- Appendices p 318 4 Coronial Brief - Transcript of video recorded interview with Ms A ~ 26 April 2012~ Appendices p 346 ® Coronial Brief -Transcript of video recorded interview with Ms A ~26 April 2012 — Appendices p 347 ¥ Coronial Briof -Transeript of video recorded interview with Ms A ~ 26 April 2012 — Appendices p 347 4 Coronial Brief -Trausoript of video recorded interview with Ms A —26 April 2012 — Appendices p 347 'S Coronial Brief -Transcript of video récorded interview with Ms A ~ 26 April 2012 — Appendices p 347 4 Coronial Brief -Transcript of video recorded interview with Ms A +26 April 2012 — Appendices p 350 ” Coronial Brief -Transcript of video recorded interview with Ms A —26 April 2012 — Appendices p 350 '8 Coronial Brief -Transcrip! of video recorded interview with Ms A ~26 April 2012 - Appendices p 358 '® Coronial Brief -Transeript of video recordéd interview with Ms A ~ 26 April 2012 — Appendices p 358
she had become aware that she wasn’t well, she repeated that she and her husband were just
“rocking the babies because they wouldi't stop erying.?*"
34, Later again in the interview, she said “/ remember ‘f was thinking maybe when I was shaking them like this or maybe shook them too hard tying to seitle them” Asked “Is that what happened?” she said “And I remember doing it like this and. maybe | went too hard with that point.and without realising the ~ just to iry and settle them +7 was just thinking... Maybe 7 went too fast and when I held them in my arms when 1 was rocking them, “24. She repeated this theme in a number of subsequent answers.
35, Later in the same interview she said that she was “maybe holding them too tight” Throughout the description of her interaction with the twins, Ms A insisted that she was simply trying to settle ther.down and get them to stop crying. She repeated her emphatic denial of ever dropping thé children. She was adamant thai she. did not intend to kill AA She went on to concede that she-inay have been shaking AA “too hard’© Latei'still she was asked “You shook AA Answer “J shook her like thai." :
36, 1 is not clear from the interview whether she demonstrated how she believed she had shaken.
AA or both twins. She was consistent in saying that she didn’t know she was hurting them, “ wasit't worried abou hurting them, it was just when J got that frustrated and it just, sort of, happened I supposed ‘cos when I'm - when T was sane I was. okay2?* Shortly afterwards she agreed that she might have shaken both of the twins and then stated that she in fact did so and that she itiay have done so more than once.”
9 Coyonial Brief -Transcript of video recorded interview with Ms A ~ 26 April 2012 - Appendices p 362
2 Coronial Brief -Transcript of video recorded inferview with Ms A +26 April 2012 — Appendices p 370
23 Coronial brief “Transcript of video recorded interview with Ms A — 26 April 2012- Appendices p 375
4 Coronial brief -Transcript of video recorded interview with Ms A = 26 April 2012- Appendices p 376
5 Coronial brief -Transcript of video recorded interview with Ms A ~26 April 2012 — Appendices p 378
26 oronial brief -Transcript of video recorded interview with Ms A — 26 April 2012 — Appendices p 382
2? Covonial brief -Transoript of video recorded interview with Ms A — 26 April 2012 — Appendices p 388
28 Coronial brief Transcript of video recorded interview with Ms A — 26 April 2012 + Appendices p 390
® Coronial brief -Transoript of video recorded interview with Ms A — 26 April 2012 = Appendices p 391
She went on to repeat her explanation that the twins simply would “scream and scream and scream”. and not being able to-help them. She later said “J wish I'd taken the anger out on myself instead of shaking the girls?” Asked after that whether she believed she may have “gripped them to tightly at times?’ she sald “F think I might have, yeah” and agreed that-she had
“shaken them more than once,”**
Results of Autopsy
On 26 April 2012, Dr Linda Les, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on AA
She was found to have the following injuries:- a) Left temporal and lefi frontal skull bruises; b) Thiee healing right parietal skull fractures c) Four right parietal skull fractures, one recent, three healing
d) An acute on subacute left sided subdural haematoma with secondary ischaemic brain
changes e) Fresh right sided subdural haematoma f Healing contusional injuries to both sides of the. brain
Dr Iles commented that.“‘he appearances of the skull fractures indicate both recent (no evidence of healing) and older bhuit head trauma, i.e. at least two séparate episodes of head trauma?™ She noted that there was ne accurate histological data in the literature that would allow her to accurately date the skull fractures, but-that other changes observed in the brain would suggest an injury of several weeks duration. As to the origin of the skull fractures, Dr-lles commented:
“The presence of skull fractures of varying ages is indicattve of bhint- head trauma. The deceased was born via elective caesarean section, As Jar as | am aware there are no accounts of this infant sustdining aéeidental tiéad trauma; regardless the extent and
*° Cotonial brief -Transcript of video recorded interview with Ms A 26 April 2012 — Appendices p'393 4 Coronial brief -Transcript of video recorded interview with Ms A 26 April 2012 — Appendices p 409 22 Coronial brief -Transcript of video recorded interview with Ms A 26 April 2012 -- Appendices py 414 % Coronial Brief p52
42,
multiplicity of the skull fractures observed is not consistent with accidental injury. Whilst these fractures ave consequent to the application of blunt trauma to the head on more than one occasion, I am unable to say whether these fractures are due io blows to the head, or more sustained blunt force to the head, ie, forcefidl squeezing of the head,’”4
While Dr Iles noted a number of findings, such as subdural bleeding and retinal haemorrhages, which may be seen in instances of excessive, violent shaking of infants, she commented that in this instance the severity of the injury to the skull and underlying brain were such that she could not differentiate injury from blunt force trauma and more subtle injuries that might be observed
in forceful shaking.
Dr Llés observed that the various rib fractures were in keeping with forceful squeezing of the chest. With respect to the metaphyseal fracture of the distal right radius, which showed minimal evidence of healing, Dr Iles opitied that this may be consequent to a shaking type injury.
AA's cause of death was found fo be head injuries.
Criminal Proceedings
44,
On 21 August 2012, Ms A was arrested and re-interviewed, At the conclusion of the interview, Ms A was charged with the murder of AA and intentionally causing serious injury to BA
After a committal hearing, the Director of Public Prosecutions sought an expert opinion from Consultant Psychiatrist, Dr Grant Lester of the Victorian Institute of Forensic Mental Health.
After reviewing Ms A's history and interviewing ber, Dr Lester concluded that in his view, at the time of AA's ~death and for some weeks prior, Ms A was suffering from a
depréssive syndrome related to the post natal period.
The murder charge was not pursued and Ms A was subsequently indicted on one charge of infanticide in respect of AA's . death, and one charge of recklessly causing serious injury in respect of BA Ms A pleaded guilty and was convicted on 28 March 2014. She was
released on a Community Corrections Order for one year.
In his senteiicing remaiks*, Justice Bongiorno indicated that this course, that is indictment on an infanticide charge as opposed to a murder charge, “was entirely appropriate.” His Honour questioned whether the ‘recklessly causing injury’ charge was supported by the evidence given Ms A's mental state al the time, but accepted that Ms A plea meant the charge was
established without the Crown being obliged to prove the facts supporting it.
34 Coronial Brief p53
35 DPP v QP X [2014] VSC 189 (28 March 2014)
48,
49,
Evidence was reecived-at the plea hearing from a nuniber of mental health practitioners who had reviewed Ms A some of whom were involved in her ongoing care. There was very little, if any, disagreenient between them as to the psychiatric aspects to the dase, Psychiatrist, Associate Professor Ruth Vine, gave evidence that atthe time of the death, Ms A was “sleep deprived, felt guilty and anxious at her inability to soothe and comfort the twins and
2936
developed a significant mood disorder.” They all attested to her ongoing depression, grief and
despair as a result-of what had happened.
In his sentencing remarks, Justice Bongiorno acknowledged that the exact mechanism of the infliction of AA's fatal injuries was difficult to determine, but stated that it was cleat that they were inflicted by a loving mother suffering from significant-emotional and psychological compromise. His Honour opined that. Ms A's moral culpability with respect to the death was either non-existent or of such a low degree as to be negligible and that no Court could
punish her more than she had been punished by-the tragedy itself.
Issues for Coronial Investigation
AA's death occurred in Victoria and was unexpected, violent and the direct result of injury.
For those reasons, her death was a reportable death pursuant to section 4 of the Coroners Act 2008 (Vic) (the Act”) and one which a Coroner is required to investigate under section 15, for the purposes of finding the identity of the deceased, the catise of death and the circumstances of the death.
As is conventionally the case, the cororlal. investigation into AA's death was effectively suspended while related criminal proceedings were on foot. At the completion of those proceedings and the expiry of relevant appeal periods, a copy of the original Victoria Police .
criminal brief of evidence was provided to this Court so that the-coronial investigation might
resume.
Ordinarily, where a death is suspected to-be the result of homicide, an inquest is mandated as part of the coronial investigation. However, sub-section 52(3)(b) of the Act provides that a coroner is not required to conduct an inquestinto a suspected homicide, where someone has been charged with an indictable offence in relation to the death, Section. 71 further provides that no findings need be made where an inquest is not held for this reason and ihe making of findings would be inappropriate in the circuinstances, Mindful of those sections, and-the more general
objective of avoiding duplication of investigations set out in section 7, | reviewed the cfiminal
% DPP v. OP X [2014] VSC [89:28 March 2014)
33,
brief provided by Victoria Police and considered the necessity and utility of further coronial
investigation in this case.
There were issues relevant to the circumstances of AA's — death which required further
investigation. They were:
The-timing and dating of the injuries to the twins in the context of considering whether such injuries cotild or should have been detected during any presentation of the twins to health care service providers, specifically the RCH Emergency Department.on 11 March 2012; the RCH Unsettled Babies Clinic on, 19. April. 2012, the Moreland MCH Service on 15 March 2012, 30 March and 24 April 2012, and the General Practitioner vision 10 Apri] 2012.
The bruising detected by the two separalé MCH nurses at Moreland City Council at the visits at four weeks of age, (30 March 2012) , and eight weeks of age, (24 April 2012), and
whether:
a. the detection of the bruising. should have pronipted notification to Department of Health and Human Services (DHHS) pursuant to mandatory reporting requirements
or further action beyond that which was actually taken; and b. The arrangements for the recording and sharing of information and records within MCH Services and other health service providers are appropriate.
The assessment and management of Ms A in light of herpresentation, comments and scores on post-natal depression screening test conducted by her GP on [0 April 2012, the MCH nurse on 30 March 2012 and the RCH Unsettled Babies Clinic on 19 April 2012, and
whether: a. it is reasonable to suggest that the seriousness and immediacy of Ms A °s mental health crisis should baye béén identified at an earlier point; and b, the risk to the infant in the context of Ms A's ments] ill health could or should
have been identified and if so, what-could or should have heen done to address that
tisk,
With these matters in mind, | obtained further records and statements and at a’‘mention hearing
on 22 July 2015, these three issues were settled as the matters to be explored at inquest,
As it emerged, the two issues which were most directly in focus at the inquest itself were issues
2 and 3, Issue | (the dating of the injuries and the possibilty of more timely detection on
Pape 15 of ft
examination of the twins) was tot explored‘in detail at inquest given the thorough treatment of
this subject in an Expert Report prepared for the Court by Dr Ciara Earley.7”
For the purposes of the coronial investigation; and the inquest in pasticular, it was not in dispute that AA's death was caused by Ms A whatever the precise mechanism and timing of
the injuries inflicted.
I formally find that AA's death was caused by her mother, Ms A
Overview of the Evidence
There was a comprehensive coronial brief cormpiled which included the materials from the original criminal brief} statements and records from health service providers with whom AA had come into contact; statements from both AA's parents; relevant. policies and guidelines relating to thé assessment and care of infants and the assessment and treatment of perinatal depression; and statements provided by representatives from the Department of Education and Training (DET) and the Department of Health and-Human Services (DHHS) about. the relevant policy context for the issues-under consideration; All of the material included in the coronial brief torms part of my investigation arid has been considered in the preparation of this Finding, In addition, the following witnesses were called to give oral evidence and answer
questions at inquest: a Dr Clara Barley, Consultant in Forensic Paediatric Medicine « Ms Atine Kinston, Maternal and Child Health Nurse, Moreland City Council » Ms Roslyn Monagle, Maternal and Child Care Health, Moreland City Council ° Ms Joan Meyers-Braun, Maternal-and Child Health Nurse, Moreland City Council ® Dr Anne Dawson, Unsettled Babies Clinic RCH e Associale Professor Harriet Hiscock, Director Unsettled Babies Clinic RCH » Dr Sani Zagarella, General Practitioner
Witnesses called at the inquest-gave evidence consistent with their statements
3? Dr Ciara Barley, Consultant in Forensic Paediatnc Medicine.at the Victorian Forensic Paediatric Medical Service of
the Royal Children’s Hospital and Monash Medical Centre, report dated 1 May 2015:
61,
The representatives of the DET and the DHHS who had provided writien statements for the coronial brief were not called to give evidence at inquest, However, further material was obtained from them by. way of answers to written questions provided to them after the
conclusion of the inquest.
(did notcall AA's mother, Ms A to give evidence al inquest. After considering the matter and hearing submissions; I decided that-it would not be appropriate for her to be called, 1
relied on the view of her psychiatrist, Dr Carol Harvey, which was conveyed to me via Ms
A's legal representative. Dr Haryey’s view was that it may have been damaging to Ms A's menta) and ‘emotional health if she was required te give evidence. Of equal importance was the fact that ] did not expect that Ms A would be able to add anything at all
to the information she had provided to the police at interview and ieferred to above at paragraphs 27 to 37 above, and to the statement, dated 7 October 2015, she made for the purposes of the coronial investigation, None of the interested parties pressed-a subtnission that
she Gught to be called to give evidence.
Issue One: Timing, likely presentation and detectability of injuries
62,
The issue of the dating of AA's injuries was covered by the expert witness, Dr Earley of the Victorian Forensic Paediatric Medical Service (VFPMS). Dr Earley gave evidence at inquest in terms consistent with her very detailed expert report.” She examined the entice medical record in respect of both AA and BA and statements provided by practitioners involved in their care. She noted the-radiological surveys performed both anti-mortem and post-mortem ip yespect of AA She exainined all the relevant specialist reports, including the post-
mortem report authored by Dr Iles and referred to.above.
Dr Harley catalogued AA's — injuries consistently with -Dr Ies, who -had performed the autopsy. Based on the injuries doeuitiented, the evidence of healing and secondary ischaemic
changes, Dr Earley also concluded that: e The evidence indicated recent and previous blunt force traurna to the skull;
e The evidence indicated at léast'two, if not more, episodes of brain injury with evidence suggesting an acute haemorhage may have happened within a few days of death and a
more chronic haemorrhage may have occurred in the weeks ptior.?
48 Exhibit 3 and Coronial Brief, p. 522 e ® Coronial Brief p, 545 .
| |
« Encephalomalacia, a term used to describe softening of brain parenchyma, was noted on the left cerebral hemisphere and indicates that-it Is possible that there may have been.
episodes of trauma up to three or four weeks before death.”
« Similar fo the skull fractures, the rib fractures suggested more than one episode of ‘trauma with both recent and older injury, with the rib fractures showing radiological
evidence of healing likely to be at least 10 days old,“!
In relation to causation of AA's injuries, Dr Earley was asked whether it was her conclusion that AA was subjected to-shaking. She replied:
“Um, yes, Tmean in terms of - as a nechanism of trauma, yes, certainly, The - the retinal haemorrhages found on post-mortem, the brain findings anti-mortem on CT and postmortem, um and also the skeletal findings, would fit with the picture of shaking... yes, T would think, given that there were skull fractures and numerous siaill fractures, probably an element of shaking plus impact."”
Although Dr Earley was unable to comment more precisely on the timeframe within which AA sustained her injuries, in response to questioning, she agreed that in all likelihood AA did have underlying injuries when she was seeri on 19 April 2012, a week prior to her death, at the Unsettled Babies Clinic and on 24 April 2012, two days before her death, at the Moreland MCH Service.? Given the challenges Dr Earley had outlined in accurately dating various injury types, she was appropriately not asked to speculate on whether injuries were likely present at earlier consultations, for example at the twins’ GP visit 16 days prior to death or at their Moreland MCH service visit 26 days prior to death. In preparing her report, Dr Earley was aware of the bruising observed on both AA andBA on 30 March 2012 and on BA
on 24 April 2012, As-discussed in detai] below, she gave evidence about the significance of these bruises as possible indicators of inflicted harm and underlying injury, In her Report, however, she did not attempt to draw a direct correlation between these documented bruises and any particular train or skeletal injuty to AA or BA which was later discovered.
Likewise, she did not suggest that the ocourrence of these documented bruises ante-mortem could be particulatly relied upon in dating the brain or skeletal injuries observed post mortem.
Dr Earley was not asked about this directly. However, given that the timing, number, nature and relative severity of episodes of trauma which occurred prior to death remains entirely unknown,
I do not expect that she would have been able to draw any such connection.
ene
4 Coronial Brief p 544 — 545 and Inquest transcript p 97 — 98 *) Coronial Brief p 544
3 Inquest transcript p 121
~ Page 18 of 80
68,
At inquest, and given the evidence regarding both acute and chronic injurics, Dr Earley was asked 1o comment specifically on the timing of the injuries which ultimately caused AA's death, Dr Earley gave evidence that “the ultimate injury that led to her death would reasonably have been expected to havé occurred close to the lime of her death." She went on to explain that by this she meant a matter of days.” However, Dy Earley also later explained that there are difficulties in pinpointing whether a particular event or injury led to death and when it occured, She stated:
“The forensic feeling would be, in cases of fatal héad injury, that the insult has happened relatively soon, close to the time of collapse. But again that is — is — is relatively controversial. And we're nol suré about the degree that the. previoys injuries have contributed to her as well. Because sometimes as well it -it — it’s difficult. And again for research ta work out what has led to the final demise; is it shaking that's caused cervical spine injury and led to respiratory arrest, or is it the brain injury itself? So sometimes that Ht quite difficult io figure out,”
Dr Earley gave evidence that the fact thal no bruising or other evidence of injury was observed on AA when examined on 19 April 2012 and again on 24 April 2012 did not necessarily lead to a conclusion that the ultimate injury thal caused her demise; more likely than not
occurred after the firsi, if not both, these consultations.”
Importantly for the purposes of the coronial investigation, Dr Barley gave evidence, both in her written report and at inquest, that regardless of whether particular injuries were already present at any consultation, there may have been no clear clinical signs and symptoms, Further, she gave evidence that such signs and symptoms as were present may easily, and in the absénce of any rélevant history of abuse or trauma, reasonably, be ‘assumed to be indicative of common childhood illness.** In her Report she stated:
“Abusive head trauma in infants may have very few clinical symptoms or signs. There is a wide range of ways it which infanis may present, In severe case they can present with cardiovascular or respiratory collapse and in-an encephalopathic state which can have fatal results. Other symptoms may include irritability, poor feeding, vomiting, and occasional seizures, Other cases, in particular those with subacute and chronic subdural haemorrhages may present with more chronic symptoms such as enlarging head circumference. Due to the varied preséniation of abusive head trauma and symptoms thet overlap with other common childhood ilinesses, the diagnosis of abusive head trauma may be missed by medical professional or others.
Jin cases where skull fractures are sustained, some studies have shown that there may not be external signs of trauma such as bruising or swelling. Therefore, in the absence of a history
48 Inquest trangcript p 98 -99
| | | | | | | | | | | | ; | | | | | : | !
| | | / |
i F
Ti.
of trauma, medical professionals may not be aware or investigate for possible slull Jractures. Rib fractures may be seen in association with abusive head trauma. Although occasionally they may be found in combination with bruising to the thorax, in the majority af cases no external injuries are found, It is more common that rib fractures are found during | ihe course of subsequent investigations for example the skeletal survey or bone sean,”
Consistently, at inquest when Dr Earley was asked whether any of the injuries would have been evidetit to those examining the twins, she said:
fn relation to all the other injuries, the skeletal injuries and the brain injuries, based on your report, is it fair to say that itis quile possible that healtheare providers examining the children in-terms of - and I'm not talking about X-raying, but certainly in a normal physical examination - is. it quite possible - and I would ask you assessment on the reasonableness of this, that those boiiy injuries and brain injuries would not have been identifiable in those examinations? ---Yes, thatis true, that they may - theré may not have been physical signs on examination of particularly those bony injuries and head injuries?>°
Questioned further, Dr Earley continued as follows:
“And putting perhaps seizures to one side, but certatily in terms of irritability, poor feeding and vomiting, that those are symptoms that could éertainly - and J use the word reasonably be associated with ether childhood conditions or illnesses, including that of colic? --Yes.
Um, that is true, and that’s oné of the difficulties in ium, assessing children with potential abusive head trauma.)
She noted that this was the case in the context where there is no information known to the medical practitioner of potential abuse or no information about the possibility or risk of physical
abuse.
T heard evidence fiom Ms Kingston about the physical examination she conducted on both twins on 30 March.2012; from Ms Monagle about the physical examination she conducted on both twins on 1S March 2012 * and 24 April 2012; from Dr Zagarella about the physical examination he conducted on the twins on 10 April 2012;° and from Dr Dawson about the physical exaniitiation she conducted an AA on 19 April 2012.°° I accept the évidetice of éach about the nature.of the physical examination conducted by them. I do not cofisider that there is any basis to suggest that the physical examination was not appropriately thorough, on
each occasion, given the varying nature and purpose of each consultation.
With the-excéption of the bruises detected on 30 March 2012 and 24 April 2012, and discussed
in considerably more detail below, | accept that on each occasion no physical signs of injury
4 Coronial Brief p 546 -~ 547
50 Inquest transcript p 99
51 Inquest trangoript p 99 “Inquest tiafiscript p 302 — 303.
53 Inquest transcript p407 — 409
55 Inquest transcript p 541,
5¢ Coronial Brief p 1313-1314 and p 1328; Inquest transoript p 84.
were observed ard no other clinical signs were present which, on their own, ought to have led the various practitioners to suspect underlying head trauma, rib or skull fracture. On that basis, and again leaving to one side the bruising observed by the MCH nurses arid noi known to the other practitioners, | consider that, regardless of the precise timing of AA's _ injuties, there is no basis for concluding that those injuries could or should have beeh detected by the
practitioners who examined AA ptior to her death on 26 April 2012.
Tt was reasonable, given the history disclosed of fussy feeding, irritability and vomiting, and in the absence of anything remarkable discovered upon examination or in their family history, that the twins would be diagnosed with colic. Even with the benefit of hindsight it does not automatically follow that this diagnosis was incorrect. In that regard, I accept the following submissions, made on behalf of the RCH, but which may also be considered relevant to other practitioners;
“Following hev examination of AA ond having regard to the history provided by MSA and Mr A in respect of both AA andBA — Dr Dawson formed the view that the likely cause of the twins unsettled behaviour was colic. The fact that colic is not a diagnosis but a descriplor of symptoms does not take away from the reasonableness or appropriateness of this conclusion with respect to the twins having regard to the history provided and examination of AA that was undertaken. Dr Dawson made a contentporangous note in the medical record to the same effect.
Overall, it is submitted, there is no evidence to suggest that the diagnosis of colic was in fact incorrect regardless of whether or not either of the twins was injured at the time of consultation on 19 April 2012, Symptoms such as vorniting and irritability are present in common infant illnesses such as colic and.are not specific to or diagnostic of neurological injury. Further, colic, characterised by erping classically in the evening or late afternoon,
is a common presentation in babies under the age of four months where no organic cause of -
their unsettled behaviour has been identified,’*’
There are two further matters which require specific. mention in relation to this issue.
When the twins attended ihe Unsettled Babies Clinic on 19 April 2012, only AA was physically examined by Dr Dawson. BA in whose name the appointment had actually been thade, was asleep and was not examined. There were essentially two reasons provided for the decision not to physically examine BA The first. was that the appointment had originally been made for one twin, but at the request of the parents it was agreed to see them both. The second was that BA was asleep for the bulk of the appointment. Given the nature of the clinic, and the fact that her history and presenting complaint were in effect the sanie as AA's |, it was considered preferable not to disturb her. There was a plan to follow up with the family in
two weeks, which, according to Dr Dawon would have provided an opportunity for examination.
57 Submission on behalf of The Royal Children’s Hospital p 9
; Page 21 of 80
79,
A/Prof Hiscock, the Director of the Clinic, gave evidence that there was nothing particularly unusual in the scenario where an awake twin is examined and the sleeping twin is not woken.’ Dr Earley concurred that the decision not to.examine BA in all the circumstances, was very
reasonable?
The submission made on behalfof MrA_ on this point was as follows;
“Although it is the position of Mr A ‘that both AA andBA should have been examined on their attendance. at the Royal Children’s Hospital Unsettled Babies Clinic, it is accepted that a playsible explanation was provided for the failure to examine both twins."
| accept Dr Dawson’s rationale for her decision to only examine AA at the consultation on 19 April 2012 and do not consider that her decision attracts any criticism. In the circumstances, it-is unnecessary to speculate whether a physical examination of BA might have revealed
anything to alert Dr Dawson to the injuries the twins had likely already suffered at that time.
The second discrete matter which warrants mention is the comparison between the bruising that was noted on BA on 26 April 2012, and that which was noted by Ms Monagle two days earlier on 24 April 2012 at the Moreland MCH Service. Ms Monagle recorded in her contemporancous notes of the consultation on 24 April 2012 just-one bruise on the right side of BA's _ face. In subsequent written statemenis and at inquest, Ms Monagle clarified that what she observed was a pea sized bruise on Barty right cheek, No bruise was located in this position when BA = was examined on 26 April 2012 at the VFPMS, however, bruises were noted above the middle of her right eyebrow, another bruise just to the outer of this, three bruises on hér right lower abdomen, four small circular bruises on her left knee, and a bruise on her labia.’ In her Report, Dr Earley commented that;
“Tt is difficult ta comment whether the injuries noted by VFPMS staff on BA — whieh appear jiot to have been documented by her Maternal and Child Health Nurse when she was examined on 24" April 2012 may have been present. .... It ix not possible to accurately date these. bruises and therefore it is possible that these may have occurred in the tve days prior to BA's examination at VFPMS,
At inquest, Dr Earley again gave evidence that it is “notoriously difficult to age bruises”™ and that they can resolve quite quickly, possibly explaining the fact that no bruise was observed on
BA's tight check on 26 April 2012, For that reason, and consistent with my finding above, | do not think that the bruises that were documented on BA. on 26 April 2012, but not on 24
April 2012, suggest any shortcoming in the thoroughness of the examination conducted by Ms
58 Inquest transcript p 143
5 Inquest transcript p 135.
Submission on behalf of Mr MrA p2 6! Coronial Brie, p 147 ~ 148,
® Coronial Brief p 548
® Inquest transcript p 125,
Monagle, or support the conclusion that areas of bruising were missed or imaccuratcly
documented on that day.
Issue 2: Response to bruising on the twins
In her written report, Dr Earley explained that a bruise results from haeniorrhage into the soft tissues and skin, usually as a result of blunt force trauma. She stated that the presence of brvising on non-mobile infants raises concern about the possibility of non-aceidental injury. Dr Earley referenced a Welsh review which highlighted that bruising in non-mobile infants was very uncommon and that accidental bruising was not commonly seen on the backs, buttocks, forearms, face, abdomen or hip, upper arm, posterior leg or foot. She referenced a second study that reportedly concluded that bruising in any region for an infant Jess than four months was
thought to be suggestive of abuse.
Dr Earley stated that ihe presence of bruising in infants may also raise the possibility of an underlying bleeding disorder. She noted that there may be other features in the history, such as a family history of bleeding disorders, which may prompt investigation. She suggested that initial blood tests for example a full blood count or a coagulations screen may help in
differentiating a bleeding disorder as a cause of the bruising.”
At inquest, Dr Earley reiterated what she had stated in her written report. She agréed that bruising immobile infants under four months of age is of considerable concern, She was asked whether the two general possibilities for that bruising were deliberate infliction of an injury or a blood disorder, Dr Earley replied:
“Yes, that is true. Very rarely and uncommonly accidental cause but certainly the first two that you mentioned would be the first two that you would reasonably consider. 66
Dr Earley went on to explain why bruising in itumobile babies is of particular concer. She said:
“You mentioned thai it's particularly concerning about bruising on babies that aren't mobile, Why is it more concerning about a baby that's not mobile than a baby that is mobile?---So there have been further studies leading on from the ones that I have um mentioned and referenced. So once babies start to crawl, obviously, they are — or possibly roll but certainly crawling is more of a defining moment, that they are able to bang into things, fall on things, whereas when very young they can't move from where they're placed.
So they - they don't tend to injure themselves accidentally."
Dr Earley’s evidence about the significance of bruising in non-mobile infants was not in contest
at the inquest, and indeed was echoed by other health professionals who gave evidence,
“4 Coronial Brief p 547 - 548.
65 Coronial Brief p 548 56 Inquest transcript p 100
& Inquest transcript p 126 - 127
86,
Dr Dawson gave evidence that it. was a rarity to find a bruise on an immobile infant, that you have to be alert to it and that; where there is bruising on an infant less than four months of age, a concern may arise as to whether it is an inflicted or non-accidental injury. A/Prof Hiscock concurred that bruising in an immobile baby would at least raise the prospect of non-aceidental
injury such that questions would need to be asked.
Ms Kingston agreed that unexplained bruising in a child is a red flag and that unexplained bruising in an immobile child is an “even greater red flag." Ms Kingston agreed also that bruising in an immobile infant raises concern about the possibility of non-accidental injury,”!
When asked if arly bruising or injury on an infant of four weeks is of considerable concern, she said “J would agree that it's evident ihat the child has had a knock. Um, it would depend on the .
reasoning as ta how the bruise was there as to what level of concern it woild raise in me.”
Ms Monagle gave evidence that bruising on a non-mobile infaht constituted a “red flag straight away.””? She agreed that one possible explanation was a blood disorder and that the other was
deliberate infliction of an injury or abuse.”
Dr Zagarella also agreed that bruising on an immobile infant is absolutely a red flag for a practitioner.”> Specifically, he agteed that it is ared flag for possible intentional injury or, an
underlying blood disorder.
With respect to how bruising observed on an immobile infant ought to be followed up by health professionals, the evidence was somewhat more varied. ‘There was clear consensus that questions should be asked as to the origins of the bruising. However, there was some divergence of viéw as to whether, depending on the explanation received, further investigation
should be undertaken or referral made, and in what timeframe.
Dr Earley’s evidence was as follows:
“Would you expect that if bruising was noted, facial bruising was noted on a child or children four: weeks of age, that there will be some sort-of follow-up done in rélation to that?--~Yes, ] would expect that, some form of follow-up. I suppose it depends.dn who saw the bruising, in what context, what other information was available on what-thé follow-up should be, uin but certainly I would expect the child to be followed up by someone, or if it was appropriate ty referred on to somebody else, "7
58 Inquest transcript p 29
© Inquest transovipt p 172 - 174 ® Inquest trangoript'p: 324
7 dniquest transcript p 334
® Inquest transcript p 294
® Inguest transcript p 415
® Inquest transcript p 416
75 Inquest transcript p 553
75 Inquest transesipt p 100 -101
91,
93,
94,
However, in response to subsequent eross examination Dr Earley clarified how her response to bruising observed on an infant may depend on the explanation given for it, Her evidence was:
“So if you weren't satisfied with it, what would you do?---Well, | mean 1 - I have the benefit of being a specialised forensic paediatrician, Um, if I wasn't particularly happy with the reason given for the bruising, um, if I was concerned that there was anything else suggestive, or 1 was concerned about a bleeding disorder, 1 might start with seme basic blood tests such as a full blood counter or coagulation screen. Um, but in a- such a young infant, if [ had concerns, wn, that there was abuse, um, would probably move to doing - to something like a skeletal survey and bone sean, um, which would be the next sort of - next - probably the next more reasonable step.
And if you were satisfied with the explanation, would you do anything?---If there were - fT was satisfied and I was happy, I wéuld probably bring the child back to myself again for fither review within a short period of time, um, to follow up on their progress, and also look - ah, re-examine the child - children for further bruises; developmental progression.°"
Dr Earley indicated that, in her view, bruising on an immobile child would mandate action (for example, referral to an appropriate practitioner or service for review, skeletal survey or blood testing, and possibly mandatory reporting) at Jeast on the second occasion, although not necessarily the first, where it would raise concerns to be assessed in the context." I consider
that this is consistent with Dr Earley’s answer extracted above.
Dr Dawson’s evidence was that if she was aware of a bruise she would seek an explanation fom the parents, and discuss the information with .her supervisor, She indicated that in most cases it would require follow up.’? Her supervisor, A/Prof Hiscock, when questioned about this matter, indicated that it was difficult to speculate about the appropriate response:
“So would it be true to say that; if you see a baby with bruising, it’s beyond your expertise ro really say what's caused the bruising?---Yes, I~ think it, ah, in a - an inamobile baby, yes, I think that's - gets quite tricky. ; So really as a cautious practitioner, you would then - - -?---I'd be asking about "Have you harmed".
You'd probably refer them off, or at least admit them to the hospital?---Or I - ] would be, if 1 was-in - in doubt at all, then I'd be trying to adinit them to the hospital.
Yes. Because you'd have a low index of suspicion, and you'd want fo - - -?---it's very hard tosay. It’s really hard to say."
In response 10 subsequent questioning, A/Prof Hiscock. agreed that what, if any further steps she would take if response to documented bruising would depend on the answers she received to questions about the origins of the bruise(s) arid whether she accepted those as providing a
reasonable éxplanation."!
Inquest transcript p 129 % Taguest transcript p J11 79 Inquest transcript p 23 — 24 £0 Inquest transcript p 174
41 Ingest transcript. p (40
|
Dr Zagarella, having agreed that bruising raised both the possibility of intentional injury and-an underlying blood disorder, gave evidence that both possibilities would require investigation.
However, it was uficlear whether his answer assumed that the bruising was not otherwise satisfactorily explained or whether his answer would have rémained the same in any case, The follow up question which was put to him, and in response to which he discussed the tests and imagining he would routinely order, was premised on the hypothetical assumption that an infant had. been reférred to him by an MCH nurse for investigation of bruising,” The further questions put to him assumed bruisitig had been’ observed on two separate occasions, in which case, consistent with. Dr Earley, his answer indicated that, regardless of the explanation given, he
would order further investigations and make an referral to the appropriate service for review.
Ms Monagle’s evidence was that, as an MCH nurse, if she observed bruising in an immobile infant the least.she would do would be to write a letter to the GP and refer off for him or her to consider further investigations,’ Ms Kinston’s evidence was that her response would depend on her assessment of the explanation given for. the bruising and whether, in the context of the broader family presentation, ii was plausible. In the event that she did not accept the explanation provided, her evidence was that she would follow up with a plan of action with direct
communication with other health professionals.“
Based on all the evidence above, | conclude that bruising in an immobile infant is rare, in large part because the opportunity for accidental injury is limited. As a result, where bruising is observed on an immobile infant it raises a significant concern that the infant may have been subject to non-accidental injury. Such.a concern requires careful questioning of caregivers in order to ascertain the origin of the bruise(s), Absent the provision of a credible atid plausible explanation, upon which the interviewer might reasonably be satisfied that the infant has not been and/or is not at risk of intentional harm, further investigation must immediately be set in train, Even where such explanation is provided, I consider the cautious approach advocated by Dr Earley, which is to schedule a review of the infant within a short period of time, to be a
sensible one.
It ig in the context of those conclusions that I turn to consider the response to the bruising that was in fact observed on AA andBA = on 30 March 2012 andon BA on 24 April 2012:
82 Inquest transcript p 553-554 § Inguest wansoript p 434
54 Inquest transcript p 296
Page 26: of 80
Response to bruising observed on 30 March 2012
99,
100,
102,
103,
104,
As sunimarised in the timeline above at paragraph 15, on 30 March 2012, the A twins presented at the Morcland MCH Service for their four week consultation and were seen by Ms Kingston. They attended «with their mother and two year old brother. It was the first time that
Ms Kingston had seen the twins and the first time that she had met the A family.
Mg Kingston has been a MCH nurse for twenty-four years having qualified in 1991, She is a registered midwife. She has a post graduate qualification from Melbourne University in Infant and Parent Mental Health. She obtained that qualification in 2006. She also bas a Graduate Diploma in Child and Family Health.
Ms Kingston made two written statements in relation to the death of AA which were both included in the Coronial Brief, and she gave evidence at inquest along the lines of her
two statements,
Based on that evidence it is established that al the consultation on 30 March 2012, Ms Kingston noted that AA had a “small bruise, green in colour, 6mm in diameter on her right cheek.
BA ‘was noted to have four bruises - 4mm in didineter in a cluster on her left cheek.
One of the bruises had grazed skin and was healing.’ To assist at the inquest, Ms Kingston
dréw. a representation of the bruises on the faces of the two twins, The bruise marks were all
aad
very fain’ Despite the faintness of the bruising, Ms Kingston said they were “certcinly
22987
detectabié”*’ with the naked eye.
Ms Kingston stated thal she asked Ms A about the bruises, Ms A had said “7 don’t know what they are doing, they must be bashing each other/bashing themselves with the colic, they are like Houdini, they get out of their wraps no matter how tight T wrap them.’®* She said that Ms A went on to say that she placed the twins end to end in the cot for sleeping with their heads adjacent in the middle-of the cot. As Ms Kingston put it “his would explain how their fists could align with the other's face’ Ms A did not purport to have directly
witnessed the twins injuring each other in the manner described,
Ms Kingston considered that Ms A's explanation for the bruising was plausible” and she
accepted that the facial bruises could have occurred and had occurred as Ms A suggested,
% Coronial Bricf p 182
56 Tixhibit 12
®7 Inquest transcript p 294 88 Coronial Brief p 183
59 Coronial Brief'p 183.
5% Inquest transcript p 297
~ Page 27 of 80
108,
nainely as a result of the children sleeping adjacent to cach other and behaving in’an unsettled marmer with anns “flailing about with clenched fists"?! Ms Kingston said that she “gave consideration to the possibility of underlying blood disorder which might result in bruising easily’. She said she discussed with Ms A that any further appearance of spontaneous bruising from incidental contact should be followed up with a GP and recalled that Ms A
gave her an undertaking that she would do so.” Ms Kingston felt confident that, given Ms A's past engagement with health services, she would ‘in fact do. so.¥ Ms Kingston discussed safe placement of the babies for sleeping so they couldn’t harm each other and reviewed strategies for managing the unsettled behaviours of the babies.” She noted that “* undertook to cease positioning the twins adjacent to each other in the way that she
reportedly had been.”
Ms Kingston said she did not see the need to seek advice or support fiom a colleague or supervisor or to refer directly to policies or guidelines in considering her response to the bruises.” She did not foim the opinion that the twins were in need of protection or that “4
would not or could not protect them or that they were at risk of physical abuse."? Ms Kingston made a note of the bruises in the record of the Moreland MCH Service, but not in the
Green Books. She did not make any referrals or notifications in relation to the bruises.
During the inquest, Ms Kingston was examined at length in relation to the éxplanation for the bruises given by Ms A and her reasons for accepting them. She presented as an extremely
experienced and reasonable MCH nurse, Overall she was a credible witness.
Tt was clear that, whether it was reasonable to do so or nat, Ms Kingston did, in fact, accept Ms A's explanation for the bruising as plausible” and thatin the circumstance, and taking into account the family’s broader history and what she observed herself at the consultation, she did
not have any concerns that the twins had been or were-at yisk of intentional injury.
As explained by.Ms Kingston, her view was informied by a number of factors. The twins appeared otherwise well and were developing normally; Ms A’s tecord revealed no history
of patenting concerns; her engagement with the twits and her son was observed at the
! Goronial Briefp 554 and Inquest transcript 336 ® Cordnial Brief p 553
® Coronial Brief p-183 and $53
°4 [Inquest transcript p 351
% Coronial Brief p 184
% Coyonial Brief p 183and 553
% Coronial Brief p 554
© Inquest transcript 336
"0 Coronial Brief p 553
Page 28 of 80.
consultation to be appropriate, caring, affectionate and capable:!” she had good supports at
home from her mother and partner,’ and she had demonstrated positive health seeking
behaviours in her prior and planned contact with both the MCH service and the RCH!
experience parents never ceased to surprise with the things they thought to do,'"”
asked how she would consider Ms A's explanation for how the bruising occurred she said
“7 would say that could be an explanation for how they occurred. It could be P08
bruising, was as follows:
“certainly as a paediatrician but probably more so as a forensic paediatrician, my level of suspicion would be quite high and I'd certainly be, um, considering do I need to perform further investigation, But certainly any small child of that age, even though it's a single bratise, 1 certainly would - the - the thought ef, you know, has there been potential injury inflicted on this child, would um - it would occur to me. Also the consideration of any medical problems, Bleeding disorders, family history, those kind of things...
But just going back to the bruising, that you would consider you would need-a greater level of force, perhaps greater than what you would expect an infant to be able fo project onto
1 Coronial Brief p $53 554 and Inquest transcript p 300 “2 Coronial Brief p 554
3 Coronial Brief p 554
4 Inquest transeript p 332
'8 Inquesl transcript p 297
405 Inquest transcript p 297
107 Tnguest transoript p 331
18 Tnguest transcript p 180
Page 29 of 80 ~
|
114,
another infant, to create a bruise?---Yeah, possibly and also it's - it's not as commen.
Scratching is something that iy relatively common in infants causing themselves, whereas bruising is not *@
Asked specifically whether a baby sleeping with anothér baby and flailing about might injure the other, Dr Barley said “Whilst it’s not necessarily an impossible mechanism, if would be unusual”! She was then asked whether she considered the explanation given by Ms A to be Sfay-feiched™ |, she said:
‘It's - far-fetched is a bit difficatt to, ah, quantify. It - well, to me as a paedigtrician, but I have the benefit of being a forensic paediatrician, 1 would think itis unusual, because we do see lois of twins, and twins do sleep together, Even, you know, bigger multiples - triplets.
But they don't levid to injure each other via bruising. Um, J would - if I was given. that explanation, I would have-to think about ii, Um, I would be veluetant to accept it as, um, sort of an face value. J would have to consider it. You'd be réluctant to accept it on face value, but you might consider it?---Yes. Yeah"'"
Taking into account the available evidence, | accept that there is some limited room for clinical judgement in considering how to respond to bruises observed on an immobile infant, at least on the first such presentation. ] do not consider that the occurrence of bruises, at least on first presentation, automatically mandates further investigation or referral, itrespective of the
explanation given and the broader context within which it is observed.
In this case, | accept that there were a number of féaturés in Ms A's history and presentation to both mitigate concerns raised. by the bruises ot the twins and to indicate that the
information provided by her was likely to be honest and credible.
However, there were also matters, which Ms Kirigston was aware of, which might be regarded as peaking, tather than tempering, the concern raised by the bruises. As Ms Kingston acknowledged, familial support or not, with infant twins and a two year-old, Ms A had an enormous workload'!?, the twins were both unsettled and Ms A had already sought medical assistance in that regard; Ms A did not attend. on the last occasion because she was sick or tired, (although she appeared to indicate that this was an isolated event); and Ms A's EPDS score at the consultation was borderline. ‘When the EPDS Was followed up with further questioning, Ms A disclosed that she felt down sometimes because she couldn't help the
twins with their colic and fell sorry for them.
‘9 Inquest trariscript p 101-102 NYO Trguest transéript p 127 ‘0 Jaguest ranscript p 128 '2 Inquest transctipt p 128 ‘3 Inquest transcript p 390
116, Even more significantly, in terms of assessing the concern raised by the bruises, was the fact that Ms A did not claim to have witnessed how it occurred, and instead was offering an
explanation based on how she had deduced it must have occurred,
117, ido not consider that I need to make a finding about whether the explanation for the bruises offered by Ms A was possible or plausible. The uncontested evidence was that this explanation was no more than a speculative theory for how the bruising had occurred.’ Even accepting that this theory appeared to be a confident, thoughtful one that Ms A had carefully pondered upon,'!? in the absence of Ms A actually being able to verify how the bruises had occurred, I consider that Ms Kingston should have questioned her further, including
exploring the possibility that the bruises may have been intentionally inflicted. |
118, It is not sufficiently rigorous to state that bruising in an immobile infant is unusual and requires
explanation, and that whether or not it raises concem about non-accidental injury depends on the absence or availability of a possible plausible explanation. Bruising in an immobile infant automatically raises concer about the possibility of non-accidental injury. That being the case inore than 4 theory (regardless of how feasible and credible it was considered) ought to have been required by Ms Kingston to dispel that concern. It follows that further action from Ms Kingston was warranted in response to the bruising. Ms A's undertaking that further
episodes of bruising would be referred to her doctor was not enough.
|
about the safe placement of the twins in the cot, secured an uridertaking that Ms A :
"4 Inquest transcript p 330 "3 Inquest transcript p 303 “6 Inquest transcript p 333
Pago 31 of 80
122,
123,
would follow up with her doctor if more bruising were-to occur and made a booking for the
_ twins to altend their next routine appointinent in four weeks time.
] consider that Ms Kingston’s decision not to follow up the bruising represented a potential lost opportunity for the more timely detection of the harm to-which the twins were exposed and possibly the more timely detection of their underlyiig injuries, of which there were otherwise no
physical signs.
I accept that Ms Kingston acted honestly and conscientiously and that as an MCH nurse of considerable experience she exercised and backed her own clinical judgement. However, her approach employed a decision making process that did not appropriately weigh the potential significance of bruising in an immobile infant as an indicator of intentionally inflicted harm. In that respect, 1 consider that there is a question about whether.Ms Kingston’s prior training in respect of bruises was appropriately updated and clear as-to the level or type of response expected. In submissions made on Mr A’s behalf it is noted that Ms Kingston had not availed herself, of “any training or information in relation to bruising in the non-mobile infant until October 2012."'""
J also note with some concer that Ms Kingston’s evidence was that, faced with the same clinical scénarid today, she would come to the same conclusion.'!* I consider that this reveals,
stl 18
at least to a degree, a lack of “insightful reflective learning” as pat in the submission made by
MrA
1 do not accept the suggestion made in submissions by Mr A that I should refer Ms Kingston to the Australian Health Practitioner Agency in relation to her professional standards.
T do however strongly agree that it-is critical that she and other nurses in her role undertake training in relation to bruising on. immobile infants. The DET. have made submissions and
provided information on this ponit whicli is addressed below.
In submissions made on behalf of MrA it was-asserted that “Bad for Nurse Kingston's inaction it is likely that AA would be alive today and BA — -would not be suffering from her
permanent significant injuries.” Tam not sure that the position is: so clear.
T accept Dr Zagarella’s evidence that, ifthe twins been referred to him. to investigate the bruising afier the four week visit then he would have responded as follows:
I would routinely do some radiology, looking for skeletal trauma, looking for fractures. I would base it - given that - if we look in particular with the twins here, AA dnd BA
7 Inquest tratiscript p'323 and Submissions on behalf of Mr Mr A plo 8 inguest transcript p 338 — 339
9 Submissions on behalf of Mr MrA plo
given that they were unsettled I would probably then make.a direct and urgent referral to a *
paediatrician for formal assessment so that they have greater expertise than what I have clearly, because they're specialisis in the field and then they could order the - the appropriate investigations looking for blood disorders which could cause bruising, But generally if that was the case there would be bruising elsewhere so if it was an isolaied bruise and if wits on two occasions, as obviously was thé casein these, imaging and a direct referral would be the most appropriate thing to do.
Take away the second occasion, but on the first occasion was as twins - - -?-Yes.
There's bruising on both twins, four week - that scenario you would still say the thing to do there, because it is isolated, the important thing is to do imaging and referral?--- Yes.
And it is actually less likely to be « blood disorder, more likely to be an intentional injury because of the isolation of bruising?-—That would be the probabilities, yes.
The scéndrio would have been, if you had received that referral after the four week siage, that’s what you would have done in this case?—-Yes, would have,"
Of course, as explored in some detail already, it is not known whether any more significant underlying injuries had been suffered at that time and thus would have been detected.
Nonetheless, it is difficult to resist the conclusion that this level of focus on the physical health of the twins in light of the bruising and the concems it raised would have changed the course of
the matter.
Dr Dawson was also asked about whether, had she been aware of the facial braising observed on both twins at four weeks that may have changed lier considerations and approach, she said “/¢
may have, but I: think the main thing would be examining the baby, you know, which was done,
would have been the most important consideration"
A/Prof Hiscock was asked a similar question and replied as follows:
“Sa you've got bruising in two children ?---Mrn,
You've gol irritability. Bruising at four weeks in two children?---Yep,
You've got irritability; you've got twins; you've got a mother who's scored 17 on an EPDS; you've got @ mother who scored positively ow the question of thought of herm of herself in the last seven days. Under those circumstances, the whole picture, if you were given the whole picture yourself and Dr Dawson or yourself weren't given the whole picture, but if you were, that would sort of up the ante from the picture you were given, wouldn't it?---L would still ask, “Haye you thought about harming yourself", and that was asked. And I would still ask aboul, "Have you thought about harming.your baby", and that was asked.
And J would still - I would ask, "How did these bruises happen", and it would depend on the responses, So there was-a negative to the first two responses”?
It is speculation as to what Dr Dawson would have in fact done in the event of being made aware of the facial bruising noted by Ms Kingston, but I accept that she. would have asked the
parents about it and discussed the explanation of it. She may have brought a more sceptical
'20 Trquest transcript p $53-554 2lnqnest transcript p 152
2 Taguest transcript p 173-174
Page 33 of 80.
frame of mind to the explanation, although given all of the other factors which led her to accept that there was no risk of harm to the twins when she saw them on 19 April 2012, it is on balance unlikely that she would have considered further action was required, particularly bearing in mind that it was by this stage 19 days after the observations made by Ms Kingston of bruising
on both twins,
Résponse to bruising on 24 April 2012
133,
135,
As summarised in the timeline above at paragraph 21, on 24 April 2012, the A twins presented at the Moreland MCH Service for their eight week consultation and were seen by Ms Monagle. They attended the appointment with both their parents and two year old brother, Ms Monagle had reviewed the twins at their two week assessinent, and was also familiar with the family having conducted a number of routine asgéssments in relation to their son, CA
including one of1.19 March 2012.
Ms Roslyn Monagle is also a highly experienced MCH nurse. She was first registered in 1972, then. registered as a midwife in 1974, She has subsequently completed various certificates and
worked in maternal and child health nursing since 1977.
Ms Monagle made three written statements in relation to the death of AA which were both included in the Coronial Brief, and she gave evidence at inquest along the lines those
statement statements, '**
Based on that cvidence it is established that, at the consultation on 24 April 2012, Ms Monagle observed injuries on BA described as pea sized bruising on the right cheek and a small seratch on the lefi cheek. The injury was “like a pea shape” on the “right cheek bone”. It was
“very light.in colour and there was a scratch in the area.of the left cheek bone”. '*4
Ms Monagle stated that she did not think the parents were aware of the marks before she pointed them out. She said “f don't think Mr A had noted” and “I remember M84 saying that she. thought it happened about two days earlier bit .. 1m not 160 sure what —1 don't know what-MY A had
said. 25
In describing the bruising and scratching,.Ms Monagle said:
“From your recollection of looking atthe serach and what you described as a pale or a light brutse?--Yeah, it's own - it was only verp pale, Um, yeah.
Would it be something you would expect you would see with normal handling and bathing and feeding of the children; something you would notice? ~:Ah, yes, it was very noticeable,
13 Exhibits 13 and 14 '4 Inquest transcript p 413
#25. faquest transcript p 415
Page 340f80
138,
139,
140,
for some of fhem.
because I stopped what } was doing - about to do, um, as soon as 1 saw it, and that gives me as a Maternal and Child Health nurse a red flag straight away, .Uin, and so then t had to do a risk assessment. So Tf actually stopped the conversation that 1 would've kept going on, id go into a risk ussessment, and asking the parents, “6
In telation to questioning the parents about what they thought had happened, her evidence was:
"T actually - I can't recall everything, 1 - I know that we talked about the bruise, 1 know we mentioned CA and I asked specifically, "Da you think CA has caused this?" I - I'm unsure of ~ of how beth M84: and Mt A answered those questions.
Is it fair ta say, you didn't réaily get an explanation. No one really knew haw that happened?--Mm. Yes?"
Ms Monagle’s evidence was that a discussion ensued with the A's about the need to closely supervise toddlers around newborns.'*8 She could not recall who first introduced CA.
into the conversation, however, she did.recall asking the parents whether he might have inflicted
the injury.!?°
Mr A's evidence was that he remembered being told of bruising above BA's eyebrow and the scratching on the cheek. He said that he thought that Ms Monagie showed the injuries to him. Asked his reaction, the evidence was:
“E was shocked, | was astounded. J had no -f had - I just couldn't comprehend how they gol there, 1 Was speechtlesy...1 remember Roz asking me about them and J was-speechless, { didn't iow how to answer her because 1 wasn't sure haw they were there. She may heave asked the question to M8& but was in and out of that room all the time looking after
Asked about Ms A's response at the time, he was vague but'said “/ Anow she blamed CA Pye
Al any rate, it was not in contest, that ihe As were not able to provide an explanation for
how the bruise bad occurred.
Prior to or diiring the consultation, Ms Monagle did not read Ms Kingston’s notes from the four week assessment.” She was therefore not aware that the twins had béth presented on that oveasion with facial bruising, and that Ms A had explained it with ‘a theory that the twins must have been hitting each other because of the way they were positioned in the cot. She, was not aware that Ms A had undertaken to take them to the doctor if it oceurred again. Neither
of the As mentioned that the twins had bad facial bruising before.
126 Inquest wanscript p 132 127 Inquest transcript p 415 128 Inquest transcript p 416 '29 tquest transcript p 414 130 Tagquest wanscript p 241 ‘4 Inguest (ranseript p 242
'X2 Coronial Brief p 558
142,
144,
146,
148,
149,
Ms Monaglé was also not aware that Ms A had undertaken an’ EPDS’ on 30 March 2012
and had a borderline score of 12;
At this consultation, Ms Monagle observed that the As were tired, frustrated with medical advice,’ struggling with the unsettled twins and concerned about their poot feeding and how it
might be compromising their growth!"
Ms Monagle determined that BA should be reviewed by her GP and prepared a referral letier to *GP” in which she referenced the bruise on the right side of BA's face and noted that the parents did not know how. it had occurred but. had. noticed it ihe. previous day. She also mentioned BA's fussy feeding, poor weight gain and the receni withdrawal of the medication
‘zantac’ on advice from the RCH.!**
After hours, on 24 April 2012, having completed her other consultations, Ms Monagle also spoke to a colleague from the EMCH Service about the possibility of the A family being picked up by that Service, given the challenges they appeared to be facing (an active two year old and unsettled twins, one with a bruise on her face’possibly caused by her older brother),2° She discussed their need for some extra support, possibly in the home.3? Ms Monagle also
discussed with her colleague the merits of réferring the family to the organisation Child First."
The day after the consultation was a public holiday and the day thereafter AA died. In the circumstances, Ms Monagle did not have the opportunity to consult further with the family and
pursue any of the plans she had in contemplation for assisting them.
Ms Monagle was clear thal she approached her colleague in the EMCH Service, and-began to consider and explore plans for further supporting the A family beéainse of the A family’s general presentation on 24 April 2012, of which the bruise on BA “Was just a part.
The bruise, however, was not the solg réason for het concern and nascent plans. 139
The text of the referral letter to the-GP also indicates that the bruise was part of; but not the sdle
reason, that Ms Monagle considered that BA required review. '"°
Ms Monagle did give evidence that she considered bruising in an immobile infant to be, in itself,
a red flag because the possible explanations for it included both a blood disorder and the
33 Coronial Brief p 560
IM Inquest wanscript p 478
3 Coronial Brief p 563
136 Inquest transoript p 496 — 497 and p 518 « $19
ST Coronial Brief p 560 — 562, Inquest transeript 489 - 491 338 Coronial Brief p 560 — 561 atid Inquest transeript p 521 132 Inquest transcript p 496 — 497 and p 518+ 519
180 Coronial Brief p 563
deliberate infliction of injury and abuse.!4! In Ms Monagle’s. opinion, the most appropriate
course of a¢tion with bruising on an immobile infant was to send the child off, at the very least,
2 She did precisely that in this case by typing a
to a GP for review of the causes of the bruising, letter for the As to take to their GP. Further, and I accept her evidence on this point, she made another appointment for the twins in one week's time, commenced a process for referring the family to the EMCH Service, and intended, timetable permitting, to try and visit the family
at home it a couple of days.
The question is whether Ms Monagle responded adequately and with requisite urgency to the
‘red flag’ represented by thé bruise on BA on 24 April 2012,
In approaching this question, it is necessary to say something about the fact that Ms Monagic omitted to read the notés from the previous session, where bruising had been documented on
both twins' faces.
In-my opinion, the appropriate response to the bruising on 24 April 2012, should be considered from the perspective of someone who was aware that this was the second lime one or both the twins had a facial bruise, and the second tinie that the parents were unable to say precisely how it had occurred, (ihe explanation on the first occasion having been fiaiied as a deductive
theory).
The evidence was clear that as a matter of practicality it would have been very easy for Ms Monagle to access the notes of the previous consultation.’? It was Ms Monagle's evidence that it was good practice to read the notes of the prior session and that it was her usual practice to do so, often while the parent(s) were present so that she could confirm with them any issues or plans.!“ Other witnesses confirmed that this was their standard practice.'“3 Ms Monagle
a6
agreed that this is what, she should have done'"® and that the four week notes contained
information which would have been relevant to her assessment?
The reason Ms Monagle offered for departing from her usual practice and not reading the previous notes on this occasion was that, essentially, she was overtaken by circumstances."
Even from the waiting room, the parents commenced talking immediately about their worries
Hl Inquest transcript p 416
142 Inquest transcript p 447 — 448
483 Inquest transoript p 437
1 Inquest transcript p 418 —419
143 Inquest transcript p 298 and p 105 146 Thquest transcript p 437- 438
‘47 Inquest transoript p 419
48 Inquest transcript 418 - 419
~ "Page 37 of 80
and concerns'?? and then Ms Monaglé noticed the bruise on BA and went into a Hsk assessment:'™" I accept that Ms Monagle is sincere in offering this explanation but I find it
unsatisfactory.
The very reason offered by Ms Monagle for not reading the notes was the very reason, if she had not already, she needed to do so. A review of the notes of the previous presentation and any issués or concerns noted therein would appear to be highly relevant to any risk assessment.
Indeed, at the time, both the Moreland City Council Mandatory Child Protection Policy for MCH ourses'*! and the Maternal and Child Health Service Guidelines, published by the DET in February 2011, indicated that reviewing prior records’ was part of the process of assessing an
identified concern.? Ms Monagle indicated that she was familiar with both these documents.'°?
’ l accept that as a matter of appropriate professional standards of practice,. not reading the notes
of the earlier consultation was an obligation that Ms Monagle failed to discharge.
Retuming to the question of whether Ms Monagle's response to the bruising was sufficient in the context I have outlined, I note that a number of witnesses indicated that bruising in a non-mobile
infant on a second occasion was, in their view, of particular significance.
Ms Myers- Braun, the Enhanced Maternal and Child Health nurse, with whom Ms. Monagle consulted on 24 April 2012, gave the following evidence:
“Nurse Myers-Braun. Just in relation to the observation of facial bruising on immobile infants, if you were awtre of a seenarto where immobile infants of some four weeks were observed to have minor bruising on their face at the four week mark and then again a7 the eight week assessment there was minor bruising observed on a second twin, would yoit be alerted ~ would that - obyiously we've heard this morning there's a lot of factors that are taken into aecount - -- ?
---Mimm.
wo but would just the fact of briising en two separate occasions in immobile twins, the first time on both faces, the second time on one twin, would that be something that would tirn your mind to the possibility of tbusé?-—-1 think if pou were aware of a second occasion i probably would, but you know,I've actually been in a home where I saw a toddler fling something at a baby and thé briise came up while I was sitting there. So I guess that explanation of possibly a toddler, you know, doing something, might justify it on one occasion, but} - I'm not sure, f+ I think if Thad asecond occasion I'd be very alerted. H would be a red flag for suré,
Would it be fair to say, would that red flag in itself-be enough to make you take further action, or would there be other enquiries you'd make before that stage?---You're always
\ Coronial Brief p 558 450 Inquest transeript p 418 —-419 '! Coronial Briefip 570 1% Coronial Brief p 570 and 582,
'33 Inquest Transcript p 459
160:
16).
163,
assessing the whole view of the situation and certainly you would need to follow it up, nfSd yeah,
This issue was returned to with Ms Myer-Braun.in subsequent questioning:
“You've answered some quéstions thai you've been asked by counsel assisting and you said that a siiré bruise on the second occasion would be a red flag for sure, were yous words? — Minun,
You remember giving that evidence just now?---Sorry?
Do you remember being asked if you were aware of if how « professional was aware that there'd.been bruising on two occasions in twins =~ <?---Md'mm, -- - one at four weeks und one at eight weeks, that that would be a.red flag for sure? That was your answer?
Yeah: I think ifyou saw ifyou were aware that there had been aprevious vccasion, it may influence - that you would think, but that's - 1 mean, it's all good in retrospect, when, you know...
Sure?- .
1 think the judgment was made at the time ont the information at the time. nh5s
Dr Zagarella also gave evidence that if he hada presentation with isolated bruising (which in his view was less likely to indicate a blood disorder) and it was on two occasions, imaging and a direct urgent. paediatric referral would be the most appropriate thing to do, Dr Zagarella also said that-in those circumstances he would try to take a very thorough history, and “tease out and ask the question a number of different ways to be absolutely certain what the. cause of that
bruise was?!
Dr Earley's also gave evidence on this point which 1 consider particularly perstiasive: y is I YP
"Yes, f think - ah Imean if you're looking at the whole context, for example, we've got hvins as opposed to singietons, two episodes of bruising plus in the context of unsettled, irritable iifaits, certginly I would be very concerned abéut that presentation and history and would um pursue further itvestigations, Blood investigations.and radlological investigations. ae
She considered Ms A's score on the EPDS on 19 April 2012 to also indicate “another level of concern?" She summarised by saying
“dh so 1 think putting, obviously, with the benefit of hindsight and having all the information, in a child where, if we had that all - all that information I would think um for all to - to all-service um on presentation to u fospital emergency department would have been um reconimended. "!
Baséd on all the evidence, the submissions made on behalf of Mr A contended that
" vather than handing the parents a letter to take to Dr Zagarella regarding further investigation of BA's bruising, Nurse Monagle should have made lmmediate contact with a. supervisor, general practitioner, specialist paediatrician or hospital emergency
‘4 Inquest Transcript p 520 +42) and Coronial Brief, p61, 158 Inquest transcript p 522
156 Tnquest transcript p 554 — 555
'57 Tnquest transeript p 103
'88 Inquest trangeript p 103
'59 Inquest transcript p 104
deparunent to organise further investigation whilst ihe parents were still present at the élinie.”'
Ms Monagle did not aceept the suggestion that the situation necessarily required more
' She gave evidence that had she been aware of the earlier incident of
immediate action.|¢ bruising, she still would have regarded the referral letter to the GP and the approach to the EMCH Service as a sufficient. direct response to the bruise observed on BA on 24 April 2012.
This answer, io a hypothetical question, was given in a context where it was also assumed that Ms Monagle was aware of the other family medical consultations which had occurred in the
interim, and of the examinations, assessments and plans that had been made.
In my view it is significant that Ms Monagle also gave evidence that, had she read the earlier notes, she would have asked move questions of both parents, explored whether:the sleeping arrangements ad changed and whether they had observed any other injuries in the interim,!© She indicated that if she wasn’t “overly convinced" she would have involved her coordinator or the Unit Manager to go over it again with the parents and consider next steps.’ The submission made on behalf of the Moreland: City Council is essentially that had Ms Monagle been prompted to ask more questions in this context, it is likely that it would have revealed that no bruising had been observed on the (wins in the interim by examining doctors, no bruising had ever been observed by Mr A and thai health supports and plans were in-place to address any post natal mental health concerns.'® It was submitted that based on her evidence at inquest,
this information would not have altered her course of action.
While we can now do.no more than speculate, I find it difficult to accept this submission from the Moreland City Council. Mr A's evidence is that he was not aware of the earlier bruising nor that it had been discussed at the earlier consultation. Perhaps more. critically, his evidence is that tbe twins were not placed in the cot in the sleepirig configuration suggested by Ms A that they weren't escaping their wraps or within arin’s length of each other in their big cot.’ Therefore, the possibility is certainly raised that if Ms Monagle had read the four week notes and more rigorous questioning had followed, greater: scepticism may have emerged
about the origin of the bruises.
'60 Submissions on behalf of Mr MrA pb
'6l Inquest transcript p 450 and p 499 - 500
12 Yaqueat tranéeript p 420
189 Thewest transéript p 420
{4 Inquest Transcript p 420
‘63 Submissions on behalf of Moreland City Council p15
‘6 Inquest transcript p 222
167,
170,
At any rate, I accept that Ms Monagle was confronted by a complex clinical picture on 24 April
4188
urgent medical treatment!” or that they were not developing as.expected.
1 accept that Ms Monagle is clearly a highly experienced MCH nurse and that, in responding to this complex presentation, Ms Monagle conscientiously did all she believed she. was professionally required to do in a caring and thorough manner, Consistently with the submissions made on behalf of the Moreland City Council; | accept that Ms Monagle wis very confident thai the As would pursue the referral she had given them to the GP! and the evidence suggests that Mr A did indeed make contact with the medical centrs for that purpose.!?* “Y accept that Mg Monagle planned to make arrangements for the family, with their agreement, 10 be accepted into the EMCH program and that. the timeliness with which she
intended to pursue this plan was reasonable in view of the intervening public holiday.
However, as with Ms Kingston, | do not think Ms Monagle properly appreciated the significance of the bruise observed on BA's face as a potential indicator of intentionally inflicted injury. I do not think Ms Monagle's response to the bruise, as-a discréte issue, was sufficiently proactive
and urgent in the circumstances.
The parents had no explanation for the bruise. It was (he second time that one or both the |
immobile twins bad presented with a bruise, a rare and 'red flag’ presentation. It was the second time that a parent could not definitively say how the bruise had -oceurred,. The bruise coirésponded with poor weight gain in BA and’ with both twins being very unsetlled. Even so
the As were not directly questioned about the possibility of physical abuse. Where Ms
‘Kingston had: acceptéd Ms A's theory for how. the bruises. had occurred on the lasi
occasion, it appears that Ms Monagle may have offered possible theories on behalf of the
parents. Notwithstanding that the bruise was unexplained, il appears that Ms Monagle did not
'67 Tnquést transeript p. 436 '8 Tnguést transcript p 437-438 ‘8 Tnguést transcript p 449
1 Inquest transcript y) 2.15
~ Pagedl of 80
173,
174,
seriously contemplate the possibility that it had been deliberately intlicted by either parent; She gave evidence as follows:
“The bruising was of u.- a pale blue - blue colour, Very small, like a pea shape. So ii wasn't actually a forve - pou know, forcefully hit. ft was in a place where a toddler could poke at and I haye seen a lot of bruising from toddlers onto infants in my 37 years and the scratch just looked like = and the nails were long of both AA and BA They - they were long and easily to be able to cause that."!7
The evidence of Ms Myers Braun also supports the conclusion that Ms Monagle, despite not having an explanation for the bruise, discounted the possibility that it may have been intentionally inflicted by anyone other than two year old. CA
“And you say in pour statement that you were told by Ms Monagle. that the toddler had hit one of the babies on the head, us reparted by the parents. fs that pour recollection of what was told?---Yeah I - the impression that she had, certainly the way her belief had jarmed at that time was that it was a - you knew, it was an accident related to-the toddler, that it - she didn't seem to have any concern or belief that it-was anything else,"
Although Ms Monagle talked of BA's bruise as a ‘ted flag’, I consider that her approach did hot adequately reflect this. It was appropriate that her assessment night take into-account what she. knew and observed of the parents. However, it-was a lapse in professional judgement that, armed with the objective evidence of a bruise on a non-mobile infant, atid without an explanation for it, she did not seriously countenance the possibility that-elther parent of another caregiver had intettionally inflicted injury. “She did not directly question the parents about the possibility of physical abuse, check the records available to her for evidence of earlier issues of concern, or consult with her supervisor or colleague in relation fo the unexplained bruise, These
are all steps that g person in-her position should have considered in assessing a ‘red flag’,
Ms Monagle did provide. the parcnts with a referral for review in respect of BA which referenced the bruise. However, | accept the submission made on behalf of Mr A that more was réquired in the circumstances. Ms Monagle should have made direct contact with a GP, paediatrician: ora hospital on that day.to arrange for investigation of the bruise, This is particularly so given that it was the sécond presentation of the twins where a bruise had been
observed, a mattér which Ms Monagle should have been aware of.
Ms Monagle's decision not to make direct arrangements for the bruise to be urgently investigated represented’ a-losi opportunily 1o detect’the harm to which the twins were exposed, io protect them from further harm and to identify. and treat their underlying injuries, prior to
AA's collapse on 26 April 2012.
‘A Inquest transcript p 489
Injuest Wanseript p 520
“Page 42 of 80
176,
As outlined above, the evidence strongly indicates (hat underlying injuries, including brain injury and rib fracture, were already present on 24 April 2012 in both twins, and I expect that these injuries would have been detected if, for example, a skeletal survey had been ordered on that day. Dr Zagarella’s evidence was that if he had been contacted by Ms Monagle immediately upon her findings on the eight week assessment, he would have undertaken a skeletal survey and referred on to a paediatrician urgently. ‘This would have led to both twins being treated for their injuries and placed in a protective environment. To be clear, { consider that this would. have. been the case even if investigations were initially only undertaken on
BA given what the findings would likely have been.
T have discussed above the evidence regarding the timing of the injury which ultimately lead to AA's death. That evidence svggests that while the ‘insult’ leading to fatal head injury generally occurs close 1o the time of collapse; and while consistently with this AA had acute. injuries suffered within days of her death, it-is difficult to be sure about the degree to
which previous injuries contributed to the progression and outcome of AA's case.
Mandatory Reporting
178:
In the context of consideting the response of the MCH nurses to the bruisés observed on the A twins, particular considcration was given to whether cither or both Ms Kingston or Ms Monagle, as mandatory reporters under the Children, Youth and Families Act 2005 (Vic) (CYF Act) should have made a report to Child Protection pursuant to séctian 184 of the CYFAct.
Such a report would have been mandated if either nurse had formed a belief on reasonable grounds that the. twins were in need of protection on the basis that they had suffered or were likely to suffer significant harm as a result of physical injury and that their parents had not
protected or were unlikely to protect them from harm of that type.
Both Ms Monagle and Ms Kingston gave evidence, which ]-accept, that they were aware of and understood their obligations under the CYF Act, Both gave evidence thal they had in the past
made mandatory notification reports to Child Protection.
In light of the evidence, particularly from Dr Barley, ] consider that bruising on a non-tnobile infant, could in and of itself give rise toa belief on reasonable grounds that a child was in need of protection and thus require.a mandatory report to Child Protection, In my view, such a view might particularly be formed -where the origin of a bruise is unverified; a bruise has been observed more than once of on more than one child; or if parents are unwilling or cannot be
relied upon to facilitate and cooperate in the investigation of the bruise.
: Page 43 of 80
i t f
181,
Nonetheless, | accept that neither Ms Kingston nor Ms Monagle formed a belief on reasonable grounds that éither of the A twins were in need of protection such that a report to Child
Protection was mandated, I miake no adverse comment on this particular point.
I do nét consider this contradicts my earlier finding that both nurses should have been more rigorous in.questioning the parént/s about the origins of the bruises and more proactive and
direct in arranging for the bruises to be investigated,
Ms Beth Allen, the Assistant Director of the Child Protection Unit, Statutory and Forensic Services Design Branch, DHHS provided a statement-and answered written questions posed by the Court relating to the Victorian Child Protection system, including about policies and guidelines for health professionals related io vulnerable infants. Ms Allen’s wiitler statement'”* referred in some detail to the ‘Viadnerable babies, children and young people at risk of harm: best practice framework for acute health services’, a resource devéloped in 2006 in collaboration between the DHHS’s Child Protection program and Victorian health services. Ms Allen noted that the Framework was not created for use by MCH nursés but that, as the document itself states, much of the content is relevant to all heaith care services and can easily be adapted for health care environments beyond the public acute hospitals, to which it is
directed!
The Framework advises health professionals to always consider. the possibility that harm to a baby, child or young person, may be non-accidental. It includes atable of signs and symptoms of possible harm and advises health professionals to act promptly and decisively to investigate any suspicions, and diagnose accurately 16 confirm or exclude possible neglect, ' The Framework then sets out a guide to action which includes a number of steps that a health
profession should consider undertaking.
Ms Allen‘s staternent and the references to the Framework prompted me; in the coritext of the case, to inquire further about what is expected when a health professional is confronted with a presentation that raises the possibility of not--accidental harm, but in isolation does not found a belief on reasonable grounds that the child is in need of protection. I put to.Ms Allen written questions about whether there is a direction or expectation that health ptofessionals in that circumstance would-make inquiries with other services and/or undertake investigations in order
to substariliate or give context to a suspicion of non-accidental harm before reporting. I also
"3 Coyonial Brief p. 1374 '™ Coronial Brief p 1383 — {384
"5 Coronial Brief p 1387
asked whether, and to what extent the threshold for mandatory reporting assumed that some
preliminary investigation would be undertaken.
Ms Allen’s answers relevantly noted the following matters:
Section 186 of the CYP Act provides that. in the context of mandatory reporting obligations, the grounds for a belief that a child is in need of protection are matters of which a person fas become aware and any opinions based on those matters, (My
emphasis.)
Child Protection’s understanding is that it is (he responsibility of health professionals to care for a child’s health, safety and wellbeing by acouratély diagnosing, or excluding a
diagnosis of, abuse or neglect,
There is no requirement that health professionals will make enquiries of other services/agenciés about the context for a suspicious presentation, but based on the above
there is an expectation that they would do so.
There is tio direction to health professionals to undertake preliminary investigations regarding a suspicion of non-accidental harm, prior to making a report to Child Protection,
The mandatory reporting provisions in the CYF Act do not require health professionals
to prove that a child is in need of protection before making a mandatory report.’
Health professionals have a particularly important role {o play in ensuring children are safe in their fanvilies, The parameters of that rolé do not begin and end with mandatory reporting obligations, Health professionals will be confronted with signs and symptoms which enliven (or should enliven) suspicions of physical abuse without rising to the threshold of belief that mandates a report to Child Protection, The CYF Act does not require further action of health professionals in that context, bul other professional obligation will arise to inquire or investigate
further or to take steps to safeguard the safety and wellbeing of the clrild.
It is-in the context of those professional obligations, rather than the ‘statutory ones set out the CYF Act, that [have adversely commented upon above on Ms Kingston's and Ms Monagle’s
fesponse to the bruises observed on the A twins,
1% Further Statement of Beth Allen December 2015
i ; i | ;
‘Training and Guidance for MCH Nurses
188,
189,
Ms Jane Foy, the Unit Manager of the Moreland MCH Service provided a written statement which was included in the Coronial Briof!”” She stated that nurses are required to comply with established best practice professional standards, and relevantly to the circumstances of this case,
appended the following documents:
» the Moreland City Council Mandatory Reporting - Child Protection Poli¢y for MCH nurses that was in force in April 2012 (Child Protection Policy) and the. revised policy a8 published on 3 September 2014 (the new Child Protection Policy);!"* and
« the Maternal and Child Health Service Guidelines, published by the DET in February 2011,-which include.an.appendix on child abuse and neglect (the MCH Guidelines).'”°
.The purpose of the Child Protection Policy was framed as “to ensure correct procedures are
followed in PéPorting. suspected causes of child abtwe to protective services’. The listed
responsibilities of MCH nurses commenced with the following:
“Concerns realised by MCH nurses, e.g. maybe a ehild has disclosed, or there are signs that may indicate physicel injury or sexual assault.”
The policy then listed the steps that should be taken which included gathering Information from the consultation, questioning parents, reviewing prior notes and, if appropriate, consiiltiie with colleagues and known support agencies involved in the family. The Child Protection Policy stated that following these steps, if there was concern about a child’s safety a report to made to Child Protection. The new Child Protection Policy is in similar terms, however, the purpose is stated more broadly as: to promote the safety and wellbeing of children in_ Moreland and ensure the staff have a.clear process to follow when making notification to Child Protection. It is also more. prescriptive about the pracess of making a notification and contemplates that a referral
may be made to either Child Protection or Child First.
Further guidance was (and is) offered in the MCH Guidelines, published by the DET, Appendix 2 of that document is focussed on Child Abuse and Neglect and states that MCH turses need to be able to recognisé:when children have been harmed or are at risk of Hiatm-and.lists physical and behavioural indicators of different abuse types to assist professionals who work with children to identify potential arcas of concern."” The MCH Guidelines list steps that should be
followed where a conceim is present and a MCH nurse is deciding whether to make a
‘7 Coronial Brief p 566 "® Coronial Bricf p 570 and p 572 479 Tnquest transcript p 459
189 Coronial Brief p 776
192,
notification to Child Protection.'*! The MCH Guidelines acknowledge that.deciding to make a notification can be difficult and give rises to anxiety about the adequacy of the rounds for concern and the risk of alienating parents. from the MCH Service." However, the MCH Guidelines emphasise “it is iniportant to work from the principle that children, particularly infants, are highly vulnerable and unable to protect themselves. Abuse and neglect of infants has
the potential for life threatening injury, and serious impairment of brain develepment, attachment, and the development of trust and healthy relationships in later life.’?**
There is a specific section in the MCH Guidelines regarding indicators of concem for infants. It provides as follows:
Infanis ave highly vulnerable and cannot protect themselves, Their rapid body growth and brain development in the first iwo years makes them extremely susceptible to the effects of neglect and malnutrition. Their soft skull, lack of muscle development and unprotected bedy make them extremely vulnerable to head and other injuries from shaking or direct blows fo the body, Where professionals who work with infants and young children identify the following indicators (particularly where several indicators are present), consultation with supervisors/colleagues should occur, Consideration should be given to a notification to Child Protection if there is a reasonable belief that the child is in need of protection.
Indicators include:
e Eyidence of physical injury inconsistent with the chill’s age and stage of
development
e Child is listless and immobile
e Child is emaciated and pale
e Child is below expected birth weight
« Child displays inconsisient weight gain
¢ Child is born drug dependent
© Child may sleep for longer periods than would normally be expected
© Child appears depressed and unresponsive fo sacial involvement
« Child cries excessively or not at all
© Child displays self-stimulaiory behaviours, for example, rocking, head banging
e Child does not seek comfort from the parent
e Child has poor musele tone and motor control
° Child exhibits significant delays in gross and fine motor development and
coordination
@ Parent is consistently impatient.or unresponsive to infants cues
¢ Parent does not respond to assistance from the MCH nurse
» Parent misunderstands or fails to respond to.the child's cues
» Parent has part or current subsiance abuse issues
° Parent had poor antenatal care
6 Parent was aged under 20 at birth of child
& Parent is highly transient or homeless
181 Coronial Brief p 781 2 Coronial Briefp 780
183 Coronial Brief p 780
“Page 47 of 80
193,
194,
195,
196,
« Parent is engaged in a-violent relationship e Parent has.a mental iliness.!
Both Ms Kingston and Ms Monagle were questioned about. the MCH Guidelines at inquest, including parts of the document excerpted above. They both indicated that they were familiar,
at least in broad terms, with the MCH Guidelines,!*
As | have already noted, Ms Kingston and Ms Monagle pirésented as conscientious, dedicated MCH nutses. Their evidence indicated that they certainly understood their role to encompass.a gerieral duly fo monitor and safeguard the development, wellbeing and safety of the infants they reviewed, I do not think thal the deficiencies in their approach in this cage arose from a lack of familiarity with the above policies. and guidelines or a deliberate departure from them, As I have already found, | consider that they did not fully appreciated the significance of bruising in an immobile infant as an indicator of abuse, and this impacted on the rigour of their follow up
and their weighing up of risk.
Both Ms Kingston and Ms Monagle gave evidence about their professional development obligations and outlined the training that-they had undertaken, on matters including mandatory
'8e They gave evidence that they had not, prior to AA's death, undertaken
reporting.
training about bruising in immobile intants.”’ In her statement, Ms Foy indicated thal on 29 October in 2010 theré was a presentation given at the DET bi-annual: MCH Conference about battered baby syndrome which was presented by Dr Ann Smith from the Victorian Forensic Paediatric Medical Service (VFPMS) and which focussed on recognising the different types of bruising of an infant or child which may be of concern, .Ms Monagle was overseas at this
tiine,!**
Ih light of my findings about the response to bruising observed on the twins, and-the evidence about current guidelines and training for MCH nurses; | have made a comment, pursuant to
section 67(3) of the Coroners Act below.
Issue 3: Assessment of Maternal Mental Health and Asséciated Risk to Infant
At each of ihe appointments attended by the twins in March and April 2012, there was some sereening and/or assessment undertaken of Ms A's postnatal mental health, Ms A
also attended a dedicated appointment. with her GP and a mental health nurse.on 18 April 2012;
"4 Coronial Brief p 786
3 Inquest transcript p 304, 361 and p 458 ~ 460
186 Coronial Brief p 530 ~ 552 and p 555 - 557; Inquest transcript p 430 — 432 and p 452 ~ 458 and p 354 UT Inquest :transeript p 323
188 Toquest transcript p 455 and Statement of Dr Anastasia Gabriel, paragraph 67
Page'48of 80
198,
which led to referral to.a psychologist. That appointment was-scheduled for'1 May 2012, some
5 days after AA's death.
in writien statements, and at inquest, the issue was explored whether each of these assessments was appropriately thorough, or appropriately responded to, and whether consideration was, or should have been, given to the risk MsA might have posed to her twins in the
circumstances.
A number of reference documents, relevant to the issue under consideration were included in the Coronial Brief, including the “Clinical practice guidelines for depression and related disorders — anxiety, bipolar disorder and puerperal psychosis — in the perinatal period” published by Beyond Blue in February 2011' and the “Perinatal Mental Health. and. Psychosocial Assessment: Practice Resouice Manual for Victorian MCH Nurses’! published in June 2013. Witnesses from the DHHS and DET helpfully gave written evidence about the origins, purposes and use of
these documents,
Assessment.of maternal mental health and associated risk to infant 30 March 2012
As already set out in detail, Ms Kingston saw Ms A ‘and the twins 4t the Moreland MCH Service on 30 March 2012 for their four week consultation. The MCH Service Practice Guidelines 2009!°', (MCH Practice Guidelines) set out the types of questions to be asked and issues to be discussed at this consultation and in particular direct (hat a maternal health and wellbeing assessment should. be undertaken; This is a physical, social and emotional health
check which includes consideration of the risk of family violence.'”
At the inquest, Ms Kingston was asked about the MCH Practice Guidelines,” She agreed that it was the practice manual. for MCH nurses at the time of her. consultations with the A
family. She agreed that it sel out the key ages and stages consultations undertaken by MCH services and what is requited by nurses at cach. Ms Kingston stated that she used it every day and that it was on her desk.) {t was apparent from her evidence and her record of the consultation, that she did in fact undertake a. maternal health and wellbeing assessment in a marmer consistent with that outlined in the MCH Practice Guidelines. The possible exception
Was that she cotld not recall whether she had inquired about whether Ms A had a history
'8 Coronial Brief p 609
10 Coronial Brief p 803
191 Coronial Brief p 1113
2 Coronial Brief p 1142 - 1143
Inquest transcript p 430
203,
204,
208,
195 1 do not consider that anything critically turns on this. Ms 4 had suffered
of depression.
a brief episode of depression in her mid-twenties. At any rate, Ms Kingston did consider and
discuss Ms A's mental health regardless.
As already outlined, Ms A was observed to be physically well and reported that she had been since the day the twins were born. Ms A reported that she was well supported at home by her husband who: had taken time off work, and by her mother. Ms Kingston observed the interaction between Ms A and her children (CA and the twins) and noted it to be
responsive, appropriate and affectionate.
Ms Kingston administered a post natal depression screen in the form of the EPDS.
A total score of greater than or equal to 13 is generally considered a positive screen for.possible perinatal depression warranting consideration of referral to an appropriate health profession for a
raental health assessment.!%
The EPDS cannot diagnose depression — this- was confirmed by all witnesses in the case.” Likewise, the EPD§ should not replacé.a health professional's clinical judgement — despite its
specificity and sensitivity as it has a low positive predictive value of “slightly less than 50%",!%8
Ms Kingston tallied Ms A's score as 12. Ms Kingston described that as “borderline scoring which may or may nol require referral to a General Practitioner”? Thig description of the score is broadly consistent with advice given in the Beyond Blue Guidelines, which include the following Good Practice Point: "For women who score 10, 1] or 12 on the EPDS administration of the EPDS should be readministered within 2 + 4 weeks, dnd existing support
services reviewed and increased if needed."""
Ms Kingston explored Ms A's answers with her and was informed by Ms A that she felt down sometimes because she couldn’ help her babies with colic and that she “feels sorry for
them? 29!
Ms. Kingston discussed with her the methods she was using for settling the twins. She was aware-that.Ms A had been to the RCH as a result of the twins being unsettled and was
awaiting ’a follow up paediatric appointment at the RCH in relation to that.
15 Inquest transcript p 368 — 371 1% Coronial Brief p.650, 653
©? Coronial Briel’p 1533 Corondal Brief'p 1534
' Coronal Brief p 554
210,
Ms Kingston noted that Ms A's score on question 10 of the EPDS was zero, indicating that she had not had thoughts of harming herself in the last ten days°* Ms Kingston did not consider, and I accept, that there was nothing in Ms A's presentation or responses to
questions that indicated anything to the contrary.
The EPDS does not include a question about thoughts of harm to others and Ms Kingston did not directly question Ms A about this.2? Ms Kingston did not consider that there was anything she observed or was told during the consultation that raised such a:concern and invited direct questioning. 1 have already discussed this in the context of the bruises that were observed at that consultation. I accept that, bruises aside, there was nothing in Ms A's psychosocial assessment and, in particular, her interaction with the twins to clearly indicate that such direction
questioning was warranted.
Ms Kingston was satisfied that Ms A had good supports and-a good plan and specifically did not think that Ms A — was suffering any form of post natal depression, She made an appointment for the eight week review, with a notation, which I accept was intended to mean
that the family health should be reviewed at that time.2*
She advised Ms A that if she had any persistent low mood then she shouild consult her GP.
Ms A gave an undertaking to do so should any issues develop with her mental health or her coping ability,
I accept that Ms Kingston completed a maternal health and wellbeing check on Ms A and that, based an Ms A's presentation and her responses to the EPDS and general questioning, Ms Kingston's clinical assessment that no mental health-follow up was required at that time was
reasonable.
Assessinent of Maternal Mental Health and Associated Risk to Infant on 10 April 2012
214,
215,
As summarised in the timeline. above at paragraph 17, of 10 April 2012, the A twins attended at the ‘Niddrie Medical Centre with their parerits and brother and were seen by the
family GP, Dr Sam Zagirella,
Dr Zagarella graduated in 1987 and became a Fellow of the Royal Australian College of General °
Practitioners (RACGP) in.1993. He completed a Diploma of the Royal. Australian College of Obstetricians and Gynaecologists in 1992. Dr Zagarella provided two written statements and
gave evidence at the inquest.
202 Inquest transcript p 322 203 Inquest transcript 323
20 Inquest transcript p'320
Page 51 of 80,
did not experience any post natal complications and that in particular she did not experience any post natal depression or psychosis after the birth of CA
0S His physical examination of them was unremarkable and he was not
“regarding colic informed about the earlier incident of bruising.
was feeling, She told Dr Zagarclla that she was feéling stressed and tired and was not sleeping well. Although the appointment was not in fact for Ms A given her answers, Dr
Zagarella arranged for her to complete a DASS and a K10, screening tools for depression.
“validated and very useful toa? ?™,
220, He stated “Jn her responses to specific questions, she revealed that she had poor attention, poor concentration, occasional confusion, a sense of worthlessness and hopelessness and outbursts of
auger.” She denied suicidal ideation?”
221, In his evidence, Dr Zagarella described the ratings received on application of the two screening tests as follows “Yes the depression was extremély severe, anxiety severe, stress severe. Yes.
a... aecepting, of course, that they're not diagnostics"!
65 Statement of Dr Zagarella 2 July 2012
205 Tnquest transcript p 544
20? Inquest transcript p 544
708 Inquest transcript p 544
309 There was some confusion and ambiguity explored at inquest as. to. whether. Ms.A's -answers oni the originally coiipleted questionnaire had been incorrectly entered ontd the electronis file record, so as to erroneously record that she had answered “Yes Often” to a question about outburst of anger, as opposed to “yes often” to a question about speeding, and overspending. Ultimately, 1 do not consider that anything turns on this point,
4 Statement of Dr Zagarella 2 July 2012 41 Toquest transoript p 572-873
224,
226,
227,
Dr Zagarella’s evidence was, despite the high scores on the scréening test, he did not consider immediate menial health intervention was required in Ms A's case on 10 April 2012.
Significantly, Dr Zagarelila said this about Ms A's observed state:
“But in the clinical context which is the most important part of a menial state examination, she appeared loving, caring, engigéd, warm and concerned for the well-being of her children?"
He did not believe that Ms A had major depression or post-partum psychosis, He formed this view because she was “still engaged”? was able to discuss and plan for the further and appeared to be concerned for the welfare and care of her children; Dr Zagarella described Ms Ats results on the screening tests, which were not diagnostic, as suggesting that further action ahd follow up were requited and he subsequently arranged for Ms A to see the
mental health nurse, Ms Goodchild together with him at an appointment 6n 18 April 2012.
Dr Zagarella also ordered blood tests for Ms A - to ascertain if there were any underlying
processes al work that might provide an explanation for hey presentation.
There was nothing in the twins or Ms A's presentation on that day which indicated to Dr
Zagarella that Ms A was a risk to herself or the twins.
Dr Zagarella gave evidence of his extensive experience in dealing with mental health issues and managing referrals for people dealing- with those issues, [ accept that he has substantial
experience in this regard. His experience appears to be somewhat above and beyond the normal.
I accept that there was nothing which ought to have alerted Dr Zagarella to the fact that Ms Teralato, as a result of her mental state on 10 April 2012, was ai risk of harming the twins. Dr Zagarella proactively engaged Ms A in conversation about how she was fecling and coping following the birth-of the twins and in view of their unsettledness, He administered a screening tool to help him identify any concerns. When the results indicated that Ms A’s mental health required further assessment, he arranged for this occur within an appropriate timeframe, Ms, A's general presentation at the consultation, the information he had about supports available to hér and her willingness to retum for a further appointment were all factors reasonably relied upon by Dr Zagarella, to conclude that Ms A “was not an immediate risk
to herself or the twins.
212 Inquest transeript p 548
713 Statement of Dr Zagarella 2 July 2012
Asséssment of Maternal Mental Health and Associate Risk to Infant on 18 April 2012
228,
229,
On 18 April 2012, Ms A retumed to the Niddrie Clinic and was seen by both Dr Zagarella and Ms Goodchild, a Division 2 Mental Health Nurse. Ms Goodchild provided a written
statement dated 27 February 20137" and gave evidence at the inquest.
MsA was accompanied to the appointment by her husband and the twins, although they
did net sit in on the consultation.
A mental-health examination was conducted, in most part by Ms Goodchild, In her statement, Ms. Goodchild reported that Ms A entered the room “feeling tired and low in mood and anxious." She gave evidence that she had discussed the scores from the DASS and K10 testing on the 10 Apri! with Dr Zagarella before the consultation and said that she “...#7 fact t expected someone to walk in extremely depressed," Jn fact, Ms Goodchild’s observation on the day was that Ms A was tired but that she “didn’t present in anyway depressed’”"? She explained that by reference to cye contact, communication and the appropriate responses to
questions, She described Ms A as “very relaxed 78
MsA reported her daughters. as being unsettled with colic and réported herself and her husband to be stressed. They discussed strategies that the RCH had mentioned. Ms A
discussed the friends and family support she had, Ms Goodohild offered a referral to Tweedle Day residential care to assist in providing parenting strategies. As Ms A was already seéing the Unsettled Bables Clinic at the RCH, she declined that offer. She confirmed that “4
-believed she had strong supports.
Ms Goodchild gave evidence of the mental health care plan that she and Dr Zagarella then prepared for .MsA
“SENIOR SERGEANT BRUMBY: Just on the front page of that mental health care plan?—-- Yep. Under the title "presenting complaint'?---Yes,
It indicates M8“ has seven-week-old twins with calic, She also has a two-year-old who is settled in behaviour. She has support, supportive family network, husband, to assist in their care. She is struggling with the tireless care required looking after her twins, and her anxiety and depressive symptoms are increasing lo the point that she is just locked into the house. She reports she is struggling with having three children and life routine? —-M'mm.
Was that the picture, if you like, that she painted to you, in terms of your. consult?--Yes.
Um, when a person walks in to, um, start speaking to me, I always, ah, put.forward to them, "So why are you here today? Why do you think you're here, and why are you here?” Um, so thai's what she put forward io me, Um, aguin it was also when - when she said about
24 Exhibit 22
25 Coronial Brief p1030 216 Tnquest transcript p 590 257 Inquest transcript p 589 48 Inquest transcript p 589
“Page 54 0f 80
234,
236,
being locked into the house, um, that we also put the - um, J ventured info, well, what things do you do with the children, and she brought up.about going to the park and doing those thitigs, and having family support so she can provide individual care.
Now, in relation to Ms A- her relationship with her husband? ---M'mm.
Did you explore that, in terms of how she felt in terms-of being able to share her concerns with her-hisband?---She did express to me that, um, Mt A was home on, um, paternity-leave, and he was, wn, actively looking after the twins and looking afterCA — and giving her rest times. Um, as far as - she didn't express any concerns about their relationships and if she had expressed concerns about their relationship, that’s something we diso investigute because that's élso important as far as her care, But it wasn't something thal she certainly put forward?
The next:step under the mental health plan was for Ms A_ to attend a psychologist on 1 May 2012.. Ms Goodchild was not concerned about any delay between 18 April 2012 and 1 May
concerns.for Ms A's safety at dhe end of the [8 April 2012 consultation.
Dr Zagarclla’s observations of Ms A were also that “At al/ times during the appointment MsA pemained engagéd and interactive and appeared calm and relaxed? Be noted also that she was able to diseuss her difficulties “appropriately. He specifically asked how the twins
4221
were and she said they were “bese His own impression was ‘that Ms A herself also
appéared improved, in terms of her mood.and outlook
Ms A was specifically asked at this appointment whether she considered she was at risk of harming her children or herself and denied both’? Ag to a risk of harm to the infants, the evidetice was:
“You have a recollection about specifically asking her a question about whether she may have felt she was at risk-of harming the infanl?--That is a standard question that we ask, correct, yes, And the answer was in the megative?-—-Ye es. if was negative. There way no risk of harm," :
Ultimately, I agree with the submission that Dr Zagarella and Ms Goodchild conducted their consultations with the A family professionally and thoroughly. J accept on the basis of their evidence that they were careful and exercised sound clinical judgement, Dr Zagarella was,
in my view, an impressive and highly concerned general practitioner.
29 Inquest transcript p 593 -.594
2° Statement of Dr Zagarella 26 October 2015 221 Statement of Dr Zagarella 26 October 2015 2 Inquest transoxipt p $52
23 Inquest transcript p 588, -p 547
24 Inquest transcript p'546-547
237,
Ultimately J accept the submission that neither Dr Zagarella nor Ms Goodchild should have been aware, or had a proper basis to be aware that Ms A presented a tisk to her children and in
particular to AA
Assessment of Maternal Mental Health and Risk to Infant. 19 April 2012
238,
241,
243,
The twins, accompanied by both parents, attended the Unsettled Babies Clinic at the RCH on 19 April 2012. They had been referred following an earlier attendance at the RCH Emergency
Department, where a possible diagnosis of colic had been mooted.
They were seen by Dr Anne Dawson, Paediatrician, who was in her third year of advanced training in General Paediatrics. Dr Dawson provided a written statement which was included in
the Coronial Brief and gave evidence at the inquest.
A/Prof Hiscock was the Director of the Unsettled Babies Clinic at the time when Dr Dawson saw the A family on 19 April 2012. A/Prof Hiscock did not speak directly to the A
family, but Dr Dawson discussed and reviewed her assessment.and proposed plan with A/P Hiscock before the family left the clinic. A/P Hiscock provided a ‘written statement which was
included in the Coronial Brief and gave evidence at the inquest.
At the consultation, Dr Dawson took an anténatal, obstetric and postnatal history from the parents and conducted a physical examination of AA The EPDS8 is administered to all mothers who attend the Unsettled Babies Clinio?*? Accordingly, Ms A conipleted ‘an
EPDS which was reviewed by Dr Dawson.
Ms A’s score on the EPDS was 17. She had also given a.positive answer to question 10, ticking “hardly ever” to. the guestion about thoughts of self-harm over the preceding week.
Anything other than an answer of "tever" to this question is regarded as a positive answer.
Dr Dawson’s evidence was that as Ms A had positive scores on a number of questions on the EPDS,”"° that raised in her mind whether Ms A might be suffering from post-natal depression. She followed up the EPDS with further questioning of © Ms A
She had noted generally that a8 fatvas the parents were concerned “things were improving???
and she was reassured by the demeanour of the parents in the clinic, She made enquiries about the amount of support that was availablé ia the parents. She noted that Mr A was home on
paternity leave and thal the parents were alternating nights in caring for the fivins. She tiated
25 Taquest transcript p 44 and p 143 28 Inguest transcript p 15
27 Inquest transcript p 18
246,
that the previous day, Ms A had seen a mental health nurse and a GP and that a referral to a
psychologist was in place.
Dr Dawson discussed the case with her supervisor A/Prof Hiscock. The discussion included Ms A's EPDS score, positive answer to question 10, and the plans that were already in place to review and address any mental Health concerns (ie. the referral to the psychologist). They agreed a plan for the monitoring and management of the twins’ colie which Dr Dawson then discussed with the As She understood that they were satisfied with this outcome. No
further follow was organised or suggested in relation to Ms A's mental health.
A number of questions were explored at inquest in relation to Dr Dawson's response to the
family's presentation as follows:
« Did Ms A's positive screen on the EPDS indicate that she was likely suffering from
Post Natal Depression?
e Did her high score of 17 (4 above the cut off of 13) increase the likelihood that she was
suffering from depressian and/or indicate that any such depression was likely severe?
» Did Ms A’s positive answer to question 10 (about self harm) indicate that further
inquiry was warranted about risk of harm to the twins?
® In the abserice of an organic Cause for the twins’ unscttledness, did Ms A's positive score on the EPDS, indicate that further investigation was warranted about the
possibility that their irritability was secondary to intentionally inflicted injury?
These questions frained the broader consideration of whether Dr Dawson could or should have
recognised the risk posed to the twins by Ms A at that time.
In relation to the first question, as noted earlier, | accept that the EPDS is not diagnostic, | accept that a positive score, thai is one equal to or above thirteen, is best categorised as a positive screen for possible perinatal depression, rather than an indicator that a woman is likely suffering from a depressive illness of varying severity. ‘This is consistent with expért evidence provided by Dr Jenny Proimos and with the Beyond Blue Guidelines, and in particular with the evidence that the positive predictive value of a score of 13 or more is around 50 percent." This means that 50% of respondénts who score 13 or above on question 10 are likely to be suffering
from a depressive illness of varying severity and 50% are not likely to be.
*8§ Coronial Brief p 1534
| |
249,
251,
254,
256,
Therefore, although questions were put to Dr Dawson and accepted by her, on the basis that mothers who score 13 or above were likely to be suffering from a depressive illness,” 1 do not
accept that proposition as having been established on the evidence,
With respect to the second question about whether any particular significance attached to a score on the EPDS as high as 17, I note the evidence of A/Prof Hiscock that there is no proven correlation between the EPDS score and the severity of the postnatal depression” On. that basis A/Prof Hiscock gave evidence that it is not her practice to approach a score above 15, any
differently to. a score above 13.
The Beyond Blue Guidélines proyide as follows:
“A score of 13 or more on the EPDS has a greater specificity for the detection of major depression both antenatally (with a supporting stuily cited) and postnatallp (with a different supporting study cited). This score may indicate significant depression or may be associated with pre-existing personality dysfunction. Referral for comprehensive mental health assessment may be necessary,”*"!
To the extent that there might be any perceived conflict between these two positions, I do not
think that 1 am in a position to, nor that I need to, resolve. it,
Whatever the significance of a score of 17 - according to-the Beyond Blue Guidelines, from a good practice perspective, at most such a score indicales that the administering health
professional should ensure access 19 timely mental health assessmeht and management.
Dr. Dawson was aware that such an assessment had already occurred the previous day with a follow up referral to a psychologist in place. There was no reason for her to second guess the
adequacy or limelinéss of (his plan, based on the score of 17 alone.
Asked whether she got aty sense from either parent that something ‘needed to be put in place more immediately regarding psychological assessment and support for .MsA Dr Dawson
stated that she did not think this was likely given the plan that had been outlined. Dr Dawson
did not recall. getting a sense from either Ms A or MrA that there was any urgency regarding Ms A's psychological assessment" The thifd question explored was whether Ms A's positive answer to'question 10, relating to
selharm, indicated a potential increased risk of harm to the twins that should be directly
explored with Ms A
229 Inquest transcript p 39-40 24 Inquest trangoript p 189 21 Coronial Brief p 651.
+32 Inquest transcript p 20
Page 58 of $0
259,
261,
262,
The training at the Unsetiled Babies Clinic was that where there was a score above 13 or where there was a positive answer to question 10, the information should be brought to the supervisor,
in thig case A/Prof Hiscock, for discussion??? A/Prof Hiscock’s evidence was that where a
person was frankly suicidal then urgent psychiatric care would be arranged. In other cases arrangement for appropriate assessment and support in the community would be organised.”**
In this case, that had occurred already,
A/Prof Hiscock gave further evidence about a positive score on question 10 as follows:
“There is nothing in the development of the EPDS of its use subsequently both in research and Clinical practice that says if a mother scores high or if she scores positively on selfharm, that you must then.go on and ask about harm to the baby. It's not ever béen looked at in research or clinical practice or validated in any way."
Nonetheless, despite the lack of empitica]l evidence to support a nexus between a positive response to question 10 of the EPDS and likely risk of harm to a baby A/Prof Hiscock gave evidence that she teaches doctors to ask mothers who answer in the positive to question 10 whether or not they have thought of harming their baby.™® She gave.evidence as follows:
“Would that be a practice that you would do if you had a positive score to self-harm that
you would also + that would trigger you to explore the issue of harm to a child?---That's something that I tend to do, yes, certainly, bul 1 wouldn't say it's standard practice, because Ldon't think there is such a thing around the country associated with the EPDS."?2’
A/Prof Hiscock was further asked. whether it is "fair to say that that seems like an inevitably appropriate question whenever this matter is at this point on the scale? She responded:
“Probably the vast najority of women who do score positively on item 10, the EPDS, have not though! about harming. their baby and have not harmed their baby. So whether it’s clinically appropriate or not. is difficult because it’s.a very difficult question to ask. [t's a confronting question in ‘itself?---And it can alienate families from the healthcare professional when you're trying to establish at the very first meeting a trusted relationship with that family.” 2
The Beyond‘Blue Guidelines state that risk of harm to the infant can bé rélated to suicide risk in the mother™* and that whenever assessing a woman for risk of suicide, enquiries should be made
about her risk to the infant.” No research is cited in support of this particular point.
Again, to the éxtent that there is any conflict between these two positions, | do not-think that I
am in a position to, nor that I need to, resolve it.
333 Inquest transcript p 144
34 Inquest transcript 144
35 Inquest transcript 149
#36 Inquest transcript p 156 = 157 37 Inquest transcript p 148-149 238 Inquest transcript p 156, 158 29 Coronial Brief p 655
249 Coronial Brief p 657
~ Page 59 of 80
\
264,
265,
Dr Dawson stated that she could specifically recall asking Ms A about thoughts of sel harm or harming the children and being told “No”. She agreed that it was a positive response to question 10 that prompted her to ask those questions, She also agreed that whether it was question 10 or the score on the EPDS, there was enough for her to be concerned that Ms A
might be at-risk of causing harm to one of her twin babies and that was why she asked the
question"
She could not recall ihe precise manner in which she had put the question in relation to harming the children. Her best memory was that “wy usual practice will be to ask if things had um, ever been so overwhelming or difficult to manage with the baby crying that um, if she'd ever thought
29243
of hurting the baby in that situation. She could not say that she asked that particular
question but stated that to be her usual practice“?
Dr Dawson made a brief contemporaneous tote of this exchange with Ms A in the medical
record as follows: "Not suicidal/homicidal" 2"
Dr Dawson gave evidence that she had no reason to doubt the answers given by Ms A in response to her enquiries following up the answer of question 10. Moreover, Dr Dawson stated that "both parents ah, seemed um, quite happy ori that particular day and interacted well with AA w Ifyou had noted any abnormality in the interaction between M8 4 and her biby, given
ihe Edinburgh Posinatal Depression Scale, is that a matter you would have noted?—Yes."®
Laccept, that to the extent that Ms A's response to question 10 raised the possibility of risk of harm to the infants, this was directly and appropriately followed up by Dr Dawson. It was reasonable that she accepted the answers given by Ms A in this context, particularly given her broader observations of the parents' demeanour, their observed interaction with the twins and the plans and supports already in place. It was reasonable that Dr Dawson reached the
conclusion that Ms A did not posé.an immediate risk to. herself or the twins.
The final question explored in relation.to the 19 April 2012 consultation was whether, in view of Ms A's score on the EPDS, and the absence of any organio cause for the twins being unsettled, specific consideration should have been given to whether the twins had already
suffered intentional harm.
241 Inquest transcript p 35 4? Inquest transcript p 17
Inquest transcript p 17
241 Coronial Brief p 593
5 Enquest transcript p 81
The evidence was that irritability and unsettledness in infants is a very non-specific presentation.
1 accept that there is a reasonably long list of differential diagnoses that should be explored. I accept that non-accidental injury might be one of these. However, I do not consider that, given the unremarkable physical examination of AA and the healthy parent infant interaction that was observed, Ms A's elevated EPDS scoré indicated that greater clinical investigation of
this possibility was warranted.
In summary, ] accept that it was reasonable that Dr Dawson's treatment plan would be focussed on managing the twins' colic. I accept that there was no evidence to support the conclusion that Dr Dawson should have organised more urgent mental health assessment and treatment for “54
beyond that which was already in place. I accept that there was no evidence to support the conclusion that Dr Dawson should have assessed Ms A as a fisk-of harm to the twins,
or that she should have made more inquiries in that regard,
Assessment of Maternal Mental Health and Risk to Infant 24 April 2012
271,
272,
274,
As discussed in some detail above, Ms Monagle saw the twins at the cight week assessment on
24 April 2012,
At that appointment Ms Monagle examined both twins, listened carefully to the parents’ concerns about the twin's uascttledness, fussy feeding and poor sleeping. She observed closely the parents! interactions with the twins, and found them to be caring and protective. In view of her observations that they were tired and struggling with their enormous workload, she discussed the possibility of additional support for them. After the consultation she began the
process of exploring and putting in place such support.
In- relation to the mental health of Ms A Ms Monagle stated that she didn’t conduct any direct assessment of Ms A's mental health in terms of post natal depression screening on
the day. 26
Ms Monagle's focus on identifying the family's further needs for support, and attempting to sécure this, were appropriate. However, it is concerning that in the context of the parent's markedly tired and wortied presentation, Ms Monagle did not specifically turn her mind to Ms
A's mental health and whether a screen or-referral might be required.
The MCH Practice Guidelines 2009 set out the primary matters to be addressed at the 8 Week Key Ages and Stages Consultation.“7 Maternal health and wellbeing does not have the same
focus at this consullation as at the four week assessment. Nonetheless MCH nurses are sfill
M6 Inquest transcript p 427 247 Coronial Brief p 1147
276,
directed to review the physical and emotional health and social wellbeing of the family and are
directed to respond to concerns raised at previous conaultations.2“8
Thave already discussed Ms Monagle’s failure fo. review the notes of the four week consultation.
As a result of that failure, she was unaware that Ms A's EPDS score on that occasion was 12, which according to the Beyond Blue Guidelines indicated that it should be te-administered
in two to four weeks. Ms Monagle was familiar with those Guidelines"?
Ms Monagle's evidence, as to the significance of her not being aware of the borderline EPDS score on 30 March 2012, was as follows:
“If you had read the previous notes, you would have taken it upon yourself to as well, an
top of what you did do, do a further EPDS on MSA or investigate her - ~ -?---1 would probably investigate her um, a little bit further, but I thought that I had investigated her anyway.
All right, but it would have prompted you-to investigate her further? I did that anyway"""
Monagle expanded on her position in the following evidence:
“Did you ask her whether she'd seen her GP in relation to any mental health issues in the preceding days?—-No.
Did you ask her whether she was feeling depressed?---No, she said that she was just tired.
No, J understand. But did you ask-her?---But she didn't say anything about depression.
Did you ask her about depression?---No, .
if you knew that she had a positive or an EPDS of 12, would you have asked at least about feelings of sadness or depression on the - thai's an EPDS previously?---1 = I had asked her abot how she was feeling and she said that she was dred, she was concernéd about the babies, about their fussy - and she was very concerned about BA and the amount of milk that um, she had dropped quite alot. I think it was only half her Formula ov: a bit below that, if | remember rightly, and she was really concerned that it was taking such a long time forBA to - to feed, and she was very unsettled. She'd - both parents have told-nie that at the Royal Children’s Hospital, they took the baby of Zantac. So the babies have been off the reflux.medication for five days. So for me, was this meaning that they really did need the Zantac? Because before that, the babies were okay. Well, within reason. So I'm - té me, 1 viewed this as removing the Zantac of a reflux baby and then the reflux had come back, and this is why they were unsettled, and the parents were - were tired.
i understand that was your reasoning, bul what you didn’t do is you didn't have, at that stage, the knowledge of the score of 12 on the EPDS?---No.
You didn't ask particular questions about that depression; that ts your evidence?-—No.... So um, we need to take in consideration what we're actually seeing, A lot of this is the nonverbal, so this is the body language, the body language a mother has to her child. Um, this shows us if there is an attachment or a non-attachment. What she's saying - so her verbal cues to this child. So all that has to be taken into consideration.
Your practice with a woman with a score of 12, what would you do in that situation?-—-I would review what had been ah, said, whal I reviewed with the - with the mother, what she
"48 Coronial Brief p 1147 and p 1151 49 Tnquest transcript p 428 250 Inquest transcript p 437-438
279,
280,
284,
was saying, how she was saying it, and then I would work out, "DoT need to see her ina week? Dod need to see her in two or do | need to see her in four?”
I consider thal Ms Monagle's answers confirm, rather than assuage, my concerns that she did not specifically turn her mind to Ms A's mental health on 24 April 2012 and whether a screen or referral might be required.
Ms Monagle was asked a serious of hypothetical questions by different.counsel at the inquest about how she might have acied differently on 24 April 2012 if she had been variously aware of the borderline EPDS score on 30 March 2012, the EPDS score of 17 on 19 April 2012, the high scores on the DASS and K10 screens on 10 April 2012, and the mental health plan and psychologist referral in place as of 18 April 2012.2
Perhaps understandably, Ms Monagle's angwers varied depending on how the questions were
framed.
Ultimately, what emerged from that questioning was that had Ms Monagle appreciated that there had been several and recent indicators that Ms A may be suffering from post natal depression, this would have impacted on her assessment of the family's presentation and raised in her mind the possibility that both Ms A and the children were at risk of harm? |
understand that this was her position, even putting to one side the bruise observed on BA, ™
I accept also that had she been additionally aware that Ms A had already been assessed by a mental health professional, already had a mental health plan and a psychologist referral for five days hence, she rhay have considered that Ms A's mental health was already being
appropriately managed.”
She could not have reasonably reached this assessment, however, without making some inquiriesof MsA_ hirself (and perhaps re-administering the EPDS, with particular attention to question 10) to satisfy herself, given the dynamic nature of such matters, that more immediate
mental health review was not required on 24 April 2012.
Ideally, it would not have been necessary to pose so many hypothetical questions about how Ms Monagle would have responded if she was aware of Ms A's history of mental health screens, assessment and referral, 1 consider that, regardless of what information was shared, it was reasonable to expect that Ms Monagle would have made. inquiries herself’ about Ms
A's mental health on 24 April 2012, so that she was in a position to consider whether it
_ *' Inquest transcript p 439, 440, 44]
28 Inquest transcript p 466 — 437 and p 499 -500 253 Inquest transcript p 467
454 Tnquest transcript p 467
255 Inquest trangcript p 499 -500
Page 63 af 80
required further follow up from her and whether it had any implications for her, immediate risk
assessment.
Evidence of MtA and Ms A
MrA
287,
MrA gaye a written statement which was included in the Coronia! Brief and gave oral evidence at inquest. He was also represented by counsel. who had the opportunity to cross
examine other Witnesses.
I have not referred extensively to Mr A's evidence in this Finding, although 1 have
certainly read and taken account of it.
MrA was home with Ms A and the twins from the time they were born and attended
the majority of the medical consultations discussed above.
By way of background, in his statement, Mr A said that his wife struggled even before they got. the twins home and handled. them entirely differently from the way she handled CA — who
had been a relatively easy baby. He said she “just didn't seen: happy?
and that he “pud it dowit ta stress and having newhorn babies to look after.’?’ He stated that after the twins had
been home “for a@ bit, Hey were vomiting, not feeding properly, crying all the time and not
falling in to a regular sleeping pattern2”* His wife told him that the twins had colic. He
presumed that she had been told that by a doctor and simply accepted it.. He stated though that he had never himself heard a doctor say they had colic, However he did remember
“professionals advising me thai the girls were suffering from reflux and nothing more."??
He was highly critical of his wife for not reaching out for assistance and not saying aiything to him to indicate thal she needed help. He is entirely unable to account for the injuries sustained by the girls and could not understand how ‘it had happened, He remains tragically perplexed as to the actions of his wite who. ultimately admitted causing the injuries to the twins.. Perhaps the cause of his greatest anguish is that neither his wife nor anyone: cls¢ has ever told him what “she
actually did to my girls?
MrA spoke of the “heaps of support’®'” looking after-the children and that his wife had
ample opportunities to speak about her depression, He. noticed no change in her behaviour to
356 Statement af Mr MrA 20 July 2015 457 Statement 6f Mr Mr A 20 July 2015 #58 Statement of Mr MrA 20 July 2015 259 Statement of Mr MrA 20 July 2015 260 Statement of Mr MrA 20 July 2015 761 Statement of Mr Mr A 20 Tuly 2015
~ Page 64 of 80
293,
294,
295,
297,
suggest that she suffered from depression. He agreed that she was obviously stressed about the twins and that things were tense but asserted that he never saw her having an angry outbursts with the twins or with CA — He went on to say:
“During the & weeks we had the girls home I was.home all day with them. So unless she was having these. ‘angry outbursts’ when she was alone (which would not be often), I never witnessed any of them. Also our house is not enormous so if she started yelling or was upset in another room, I would know, You would hear it in the house, 262
In his oral evidence at inquest, Mr A confirmed that his wife didw’t give him any particular yeasons to believe that she was struggling, apart from the general observations of the pressures of three children, lack of sleep and difficultly feeding the twins, He said there was “only one angry outburst” That was in relation to not being able to get the girls settled and the mother not knowing what to do, He said that was the only. angry outburst he said he ever saw. At that point in time he took the girls from the mother and told her to go and get some slecp. He confirmed that his wife never discussed any concerns or worries about her emotional wellbeing
with him. There was nothing that would have caused him to ask questions about that.
Mr A was clear that he didh’t witness any actions on the part. of the mother which concerned him or appeared to be placing the children at risk, Me said “If I had wimessed
anything we wouldn't be in this situation right now. ht
The surprising thing about this case is that Ms A clearly inflicted injuries on her daughters without her husband ever being aware of it, hearing anything or observing anything. However ihis all has to be seen in the context of parents of twins who were extremely tired and suffering
the usual stresses experienced by parents of new babies.
MrA went on to describe the medical appointments at which he attended and those which
he didn’t.
He recalled no conversations with his wife at these consultations about whether she may have had thoughts about harming the children. He was firm in saying that he believed he would
yemeémber such a thing.
In relation to the administration of the EPDS tesi or other mental health screefis, Mr A bad
no recollection of his wife ever being tested.
He confirined that he was ‘never aware of an assessment that the underlying problem with the
twins was colic and only had 4 memory of being told that it was reflux.
28 Statement of Mir MrA 20 July 2015 263 Inquest transcript p 202
764 Inquest transcript p 221
|
299,
He did recall his wife discussing with him plans to.documemt feeding and sleeping-routines. This
flowed from the consultation with Dr Dawson at the Unsettled Babies Clinic.
300, He was unable to give specific answers to many questions al inquest relating to particular
consultations with particular medical practitioners,
In relation to any direct conflict in the evidence between Mr A and doctors who made specific notes following their assessment and what they told the parents, I accept the evidence supported by the documentation of the medical practitioners. In saying this I in no sense criticise Mr A He was a conscientious, hands-on father providing exceptionally strong support for his wife, backed up by tiembers of their extended families. A conclusion that he may not have heard, or may be mistaken about, what was said by particular medical practitioners at a.series of consultations when both he and his wife were tired and stressed does
not reflect adversely on im.
Mr A gave evidence that he was unaware Ms A - had been given a meital health plan and referred. to a psychologist.® However, he agreed that he had accompanied Ms A to the Niddrie. Medical Centre and was in the waiting room with the twins when Ms A saw
the mental-health nurse and GP." He did not seck to dispute that the Mental Héalth Plan prepared for Ms A was located, after AA's death, stuck to. the fridge in the A
home?4?
In relation to the specific observations by nurses of bruises, Mr A's evidence was that be was not aware of the bruising being detected by Ms Kingston at the four week consultation, He said he did not see the bruising on the twins after thal appointment, He said that when his wife came home from that appointment she did not discuss the bruising With him and he didn’t see it. Uttimatoly he had difficulty éxplaining why when a mateinal child health nurse had seen
8 He confirmed under questioning that he
bruises on both twin'’s faces he had not done so.
observed no bruising on either AA orBA at the four week point or after ~ anywhere on their bodies.*” “He said that he only became aware of bruising when advised by the maternal child health nurse.at the eight week assessment. He agreed that he was handling the babies
every day and accepted that if there had been bruising he would have noted it”!
265 Inquest transcript p 212 266 Inquest (ranseript p. 211 #7 Coronial Brief p 203 and Inquest trafiscript p 578 288 Inquest transcript p 238 + Inquest transcript p 238 279 Tiquest transcript p 239 7 Inquest transcript p 218
“Page 66 of 80
Ms A
For the reasons noted above, Ms A was not called to give evidence at the inquest.
The key points made in her written-statement for the mquest can be summarised as follows:
© She and her husband took the twins to the RCH Emergency Department when they were around 11 to 12 days old because the twins were crying all the time and difficult to setile:
« At 6 weeks of age they were taken to the Niddrie Medical Centre (Dr Zagarella), In the statement, Ms A says that she said ta Dr Zagarella “I need. help [ am not coping.” She recalls doing the DASS and the K10 screen tests. She recalls being told that her scores were quite high and that she would need follow up appointments with both Dr Zaparella and mental health nurse Ms Goodchild. She said “er thas time J did not realise how serious the depression was."
e She questioned why viore immediate action was not taken given the scores. In this context I note the evidence already reviewed in relation 1o Dr Zagarella and Ms Goodchild, they did not consider that the scores themselves dictated an immediate and \wgent mental healih intervention for Ms A
e She recalled the referral-to Dr David Collins, the psycholagist.
« She referred to the visit the Unsettled Babies Clinic on 19 March 2012 and to the Maternal Child Health care nurse two days before AA's death.
© She described the support she had from her family and her husband,
«. She referred to the police interview and her statements that she may have shaken the babies while they were in her atms, holding them and rocking thern. In this statement she said “Even now, that is all l remember doing with the girls. [ did nothing deliberate
27 Statement of Ms Ms A 7 Ostober 2015 p 6
| j
|!
| | | | : |
ta hurt them, Fam not holding any information back. I have ao meniory of anything else
I did that caused the injuries to the girls?”
e She was adamant that she did not know then that she was harming the girls and stated that she woiild have hospitalised herself if she had known that she could, She believed that she needéd help in managing the girls but thought she was getting help
appropriately. (I note that on the evidence, she was in fact receiving considerable help).
¢ Late in the statement she expresses her remorse and states that she can’t remember what
happened but is distraught at the consequences,
307, MsA ultimately stated that she now understands how depressed she was but did not realise that at the time. She expressed a hope that the coronial inquest would “improve thing for-other
parents who may face similar problems in the fiture.?™
Pursuant to section 67(3) of the Coroners Act 2008, | make the following comment(s) connected with the death: :
Response to Bruising
to the Court, the DET has provided the following relevant information:
mobile infants,2
accidental injury.27
® The amended MCH Guidelines will indicate that where bruising is noted on a non-
mobile infant, there are reasonable grounds for forming the belief that the child is in
273 Statement of = MsA 7 October 2015 p 10 74 Statement of MsA 7 Octobér 2015 p 14 275 Submissions in Reply on behalf of the DET, 15 February 2016, p t 2 Submissions in Reply on behalf of the DET, 18 February 2016, p 2
~ Page 88 of 80
309,
311,
need of protection. As such a mandatory report to DHHS Child Protection is
recommended.?”?
» Although the responsibility for ensuring registéted nurses arc abreast of relevant clnical issues primarily rests with the nurse, the Department has determined that it will provide further information, clinical updates and training to MCH nurses concerning the
significance of bruising on non-mobile infants?”
e The Department envisages that it will seek to draw on the expertise of Child Protection, and the Victorian Institute of Forensic Medicine and other specialists to develop a new seminar regarding bruising on immobile infants. Jt is anticipated that this seminar will be presented to all MCH nurses at the Department’s bi-annual conference in April or
October 2016, 77
The submission niade on behalf of Mr A was that in all cases where there is bruising on a non-mobile infant that cannot be independently confirmed as having occurred as a result of accident in a public setting, a radiological screen for accidental injury is warranted, On that basis, it was further submitted that the Moreland City Council should promulgate protocols which mandate that a referral to a GP, specialist paediatric service or a hospital emergency
department should be undertaken in all such cases.?*
I have already indicated my view that there is some limited room for clinical judgment in considering how to respond to bruising observed on an immobile infant, at least on the first such presentation, In that respect I prefer the approach foreshadowed by the DET, which would emphasise the significance of bruising and then recommend rather than niandate a particular course, | think that a recommendation of this nature in the MCH Guidelines would adequately serve to highlight the scepticism or suspicion, and concem with which any preserlation of
broising in a non-mobile infant should be approached,
I have stated that I consider bruising in a non-mobile infant sufficient in itself to found a belief on réasonable grounds that a child may be in need of protection, However, | have also indicated that T accept that health professionals may consider that bruising, in some cases, gives rise to a suspicion or concern that falls short of the reporting threshold, but which necessitates follow up referral and investigation. lt would have been my intention, therefore, to recommend that MCH
nurses be guided to pursue one or other of these paths — reporting to Child Protection or follow
27? Submissions in Reply.on behalf of the DET, 15 February 2016, p 2 278 Submissions in Reply on behalf of the DET, 15 February 2016, p 2 2” Submissions in Reply on behalf of the DET, 15 February 2016, p 2
280 Submissions on behalf of Mr A
ps
3)2.
up referral and investigation: However, | accept that such guidance may be confusing. It may introduce unnecessary complexities such as consideration of parental cooperation and likely follow: through with referral and the availability and accéssibility of appointments with other appropriate health services. On that basis the approach of the DET is to be preferred, In submissions, the DET notes that the result of a notification would be the same in any case, a Child Protection practitioner would conduct a visual check of the infant, and where injuries or symptoms of abuse are present, a paediatric forensic medical examination would be required *!
Taccept that.
The initiative being undertaken by the DET by way of an amendment to the MCH Guidelities, ts a positive and appropriate response to the lessons learnt:in this.case. In the circumstances, |
consider that it is no longer necessary to make.a specific recommendation on this point.
Assessing risk
316;
Reviewing AA's death, il is clear that none of the health professionals who encountered “**
in the weeks leading up to 26 April. 2012 concluded that she posed a tisk of harm to her twins, With the exception of my findings in relation to. the bruises, I have concluded that there is no basis for criticism in that regard. The primary indicators which might lead to concerns about-risk of harm to an infant, such as difficulties in mother infant interaction, suicidal ideation or evidence of a.sérious mental health disorder, were not present in this case. On the contrary, the manner in which Ms A engaged with, responded to and spoke of her twiné offered
assufance to héalth professionals.
This. led me to consider whether current screening frameworks are appropriately calibrated to recognise the risk to infants- that midy-arise in more generic circumstances, for example, as a
yesult of an infant being very unsettled, vith exhausted bul otherwise attentive parents.
It- also led me to consider whether assessment of risk of harm to infants in the post natal period ought to be approached.in a more routine, systematic way, irrespective of whether there are
other possible. indicators of concern.
For example, mothers are routinely encouraged to complete the EPDS as a matter of course in the weeks following birth, regardless 6f whether there is evidence of post natal depression. It is 4 broad screen and inclades.a question about thoughts of sel harm, which might otherwise not be broached. I raised the question, with two witnesses of considerable. expertise in this area, Dr
Jenny Proimos and A/Prof Hiscock (of the Unsettled Babies Clinic), whether there may be yalue
81 Submissions in Reply on behalf of the DET 15 Féebmary 2016, pa
~ Page 70 of 80
in including in the EPDS an additional routine question for mothers about whether they have had thoughts about harming their baby.
validation of the EPDS. Dr Proimos* expertise is considerable”,
research to test its validity?
would hot be sound, based on = =AA's death alone, to suggest that the question should be
routinely asked (verbally or in a written questionnaire) to every mother regardless of whether
other indicators of concern are present.
320, In reaching that conclusion, | am mindful that, in atry event, Ms A was twice asked the question (verbally) whether she had thought about, or was wortied about, harming her children
and denied any thoughts of harm. Her own evidence is that she -waS unaware that she was
harming the twins or that she posed a risk to them, :
In her response to written questions, Dr Proimos made two further pertinent points.
She was asked, “would you agree thai in the absence of these indicators, risk io infant is not routinely and directly explored in the context of screening for post natal depression or conducting a maternal psychosocial assessment?”
In her answer she noted that the current screening framework employed: by MCH nurses does recognise that risk to infant may arise in quite general circumstances. For example, she noted Appendix 2 of the MCH Guidelines dealing with Child Abuse and Neglect contains a long list of indicators of concern for infants which includes indicators such as excessive crying and poor
weight gain.?*°
and Stages (KAS) consultations and cited examples of how this occurs, which, in my view,
82 Statestiont of Dr-Jenny Proimos dated 8 October 2015 : 83 Dr Jenny Proimos is the Principal Medical Advisor in Wellbeing aud Engagenient Division of the Victorian Department of Education and Training,
284 Statement of Dr Jenny Proimos, p 14 and Inquest transcript p 150 285 Inquest, transcript p 154
236 Statement of Df Jenny Proinios, 22 December 2015 p 3
~ Page 71 of 80
325,
326,
served to illustrate that it is not only through the asking of direct questions about potential or
actual harm that risk is expected, explored or monitored.
Dr Proimos noted that the MCH Practice Guidelines prompt MCH Nurses to conduct a mental health and wellbeing check at the four week KAS consultation that includes the follow questions:
“Ask all mothers if they have experienced any of the following: Past history of depression/anxiety
Anxiety/depression
Fatigue/loss of energy
dnsonmia/hypersomnia
Significant increases or decreases in appetite
ff the mother answers yes to any of the above questions discuss information in Emotional health during pregnancy and early parenthood, Beyond Blue.
This included information in regard to the use of the Edinburgh Postnatal Depression Scale and suppori/referral options ?*?" In her statement, Dr Proimos made the point that there is no one risk assessment tool that can
accurately predict whether a child is likely to be harmed by a parent or care giver.788
I note and accept that the “primary trigger for shaking a baby is frustration and angry résulting
from ant infant's inconsolable cvving:?*’ This appears to be exactly what happened in this case.
l-note also that the cvidence is, that the generic nature of risk factors and tiggers makes a screening tool or risk assessment tool with sufficient. specificity in relation to Shaken Baby Syndrome (SBS), a considerable challenge to develop. It follows that prevention efforts must focus heavily on early engagement with parents aboiit the risk of SBS. In this context I note the ° evidence of Dr Gabriel about the NAPCAN SBS paniphlet. (see paragraph 331) The NAPCAN SBS brochure is in very clear language.
Dr Anastasia Gabriel from the DET made a statement dated 4 September 2015. She also
forwarded a Ictter dated 17 December 2015 answering a: number of questions set out by the Court.
She outlined the policy documents that applied between January and April 2012, They were the Maternal and Child Health Service: Practice Guidelines (2009), and the Maternal and Child Health Service Guidelines (2011), She outlined the practice framework for consultations under
the MCH Practice Guidelines. She noted that they are prescriptive as to activities nurses are to
287 MCH Practice Guideline 2009, p 29 388 Statement of Dr Jenny Proimos, p 14
289 Statement of Dr Jenny Proimos, yr 17
undertake at each KAS consultation.2%” The MCH Practice Guidelines specify data to be
collected and other obligations.
She noted that the MCH Practice Guidelines “act as a reminder to MCH nurses to turn their mind to the safety of the chitd at each KAS consultation.” She noted that the MCH Practice Guideline prescribes that the MCH nurse is “to provide and discuss each handout listed on the MCH framework — Promotion of Heaith and Development for the home visit KAS visit. (For the
initial home visit these handouts include the NAPCAN pamphlet ‘It’s not ok to shake babies’!
Finally Dr Gabriel noted. that the Department of Education and Training provides $8000 - $10,000 annually to NAPCAN “in order ta purchase copies of its pamphlet “It’s not ok of shake
babies'?” to be distributed to every family at the initial MCH home visit.
I note the evidence of Dr Dawson that as part of explaining diagnosis of colic to the A's - she talked to parents about the “Purple Crying” website. No material from this website was tendered — but reviewing it myself, it appears to be a valuable resource for parents, especially
those. struggling with an unsettled infant, It includes the followitig explicit information:
http://purplecrying.info/sub-pages/protecting/shaken-baby-syndrome-sbs. php
Did you know that nearly four times everyday an infant is shaken and abused?
Shaken baby syndrome (SBS) is a form of child abuse that occurs when an infant is violently shaken by @ much larger person, It is the most devastating form of child abuse as 30 percent of all infants who are shaken die and upwards of 80 percent who. survive suffer permanent life-long brain abnormalities. In fact, shaken baby syndrome is the most common form of child abuse seen in children under one years of age. So now you are probably wondering, what does this have to do with me? | would never shake my baby. Would you belleve that the number one reason a child is shaken is because a parent or caregiver becomes so frustrated with a baby's crying that they lose control and just shake them. Believe it! Research has shown that frustration with a child's crying is the number one reason a person shakes a baby. This can be hard to understand, unless you have been in a situation where no matter what you tried to calm your crying infant, nothing worked.
On this topic DF Proimos was asked “do you believe the information provided to parents currently (eg. Pamphiét NAPCAN — It's not OK to shake babies) is suffidient to draw attention io parentsfcaregivers regarding the risks of SBS,”
Her answer was: “There is a place for additional evidence based information on tatsettled infants, coping with infant crying, and the risks of shaken baby syndrome to be provided to parents by MCH Nurses and other health professionals (in addition to the NAPCAN pamphlet).
Consideration should be given to,
290 Statement of Dr Anastasia Gabriel, 4 September 2015 291 - Statement of Dr Anastasia Gabriel, 4 September 2015
2% Statement of Dr Anastasia Gabriel, 4 September 2015
336,
(i) Evidence based research projects that have been undertaken in other Australian States and Territories and overseas; :
(ii) The effectiveness of these programs in education parents about infani erying and shaken baby syndrome via written materials, educational films, and online tools; and
(iii) The wayin which parents and caregivers are engaged with this ivformation..?
Pp iS q
Dr Proimos also outlined projects which are being undertaken in Australia about the Cry Baby project. She said:
“The Cry Baby Project explored what methods were effective in engaging with vulnerable parents to access an intertictive online program that pravides them with informition and strategies on how to cope with infant crying, und strategies to improve infant sleep. The Project explored whether online promotion, promotion by MCH nurses, and/or weekly emails prompts increased the level of engagement with this interactive online program.
The preliminary findings suggest that promotion by MCH nurses and/or weekly emails prompts do-increase parents’ level of engagement with interactive online programs such as these.
Once the findirigs have been finalised the Department will consider ways to integrate these findings régarding parent engagement métliods into MCH praetice,’?™
Review of the Case by Moreland City Council
339,
Ms Jane Foy was tlie Moreland MCH Unit manager at the time. She was not called to give evidence at the inquest. However she did make a statement in which she referred to the supervision of MCH nurses, in particular whether there. is any routine audit of consultation records to check compliance with Guidelines and Practice- Manuals and whether there are
routine supervision meetings.
She referred to one focused desktop audit of certain notes that had been undertaken. I does appear that supervisors do not, as part of their supervision, review notes to consider compliance With policy and guidelines. I make no comment upon that matter. I note also that general MCH
nurses have supervision meetings every two months.
As to whether ihere were briefings, de-briefings or reviews after the death of AA or whether there are in similar cases was canvassed in evidence: Ms Kingston was asked:
“Was this case debriefed or case conferenced, aftér thé tragic outcome? No
Would that have been helpful, to do that?---It's helpful to review any case,
Bul you say there's been no review by Moreland City-Council of this case?--That is correct.
HS HONOUR: I'll just ask you the obvious question. Do you think there should have been? For the benefit of yourself and other practitioners?—--I think it would be very helpful.
Mm.
Yes,
MR HALEY: Were any guidelines or protocols promulgated by. Moreland City Council after this event in relation lo bruising in immobile children ?---No.
28 Letter from Dr Jenny Proimos, 22 December 2014
24 Letier from Dr Jenny Proimas, 22 December 2014
“Page 74 of80
341,
HIS HONOUR: I'l ask you the same question. again, Ms Kingston, Do you think that would be usefil?--I think a review of, um, training on, um, signs of physical abuse would - is - is always helpful,
I would agree with Ms Kingston that it would be “helpful” to regularly review training in respect of responding to signs of physical abuse. I note her view that it would have been helpful for there to have been a review of the case. I note also that no néw guidelines or protocols were promulgated by Moreland City Council after this evetit in relation to bruising in immobile children, There was tio furthér evidence on this matter and more may have becn done since then by Moreland City Council. Reviews of cases such as this leading to death or other significant
incidents, ave routinely undertaken by hospitals and other institutions. It is surprising that no
review, as such, was conducted by the Moreland City Council but I make no further comment on
the point.
Information Sharing ~ The Green Book
347,
All health professionals involved with the family over the eight week period leading up to 26 April 2012 weré engaged in @ similar endeavour, that is, to ensure the health, safety and wellbeing of the twins and monitor and support maternal wellbeing. In approaching this task, they did not have the benefit of each other's observations and examinations, except to the extent
that information was relayed via the parents.
Each practitioner would almost certainly have benefited from information from the others, about
ihe bruising, mental health screens, diagnoses, treatment plans.
As a result, at inquest there were many hypothetical questions about how. assessments and
responses may have been different with a more complete picture,
In this context, there were a lot of questions about the Green Book - what was and wasn't
recorded and why and whether the Green Book was taken to and checked by other practitioners anyway.
This prompted me to pose questions to the DET about the Green Book’s intended use.
In her résponse to those questions: Dr Gabriel of DET advised as follows:
“The. Green Book is designed for use by parents and MCH nurses to record their child's milestones, health, growth, development and immunisation throughout their childhood, The Green Book-alsq allows for parents to add in personalised details about their child's health and development and provides plasti¢ sleeves for important documents.
245 Inquest transcript p 340
Information is often added to a child's Green Book by MCH Nurses and the child’s parent at each of the child's Maternal and Child Health consuliations (Known as the Key Ages and Stages consultations).
.. Parents are encouraged to take their child's Green Book along to their appioiniments-with other health professionals in respect of their child. However, as far as the Department is aware (from anecdotal evidence), health professionals (other than MCH nurses) do not have the expectation nor do they require that parents will bring their child's Green Book to consultations.
The Department does not currently collect information regarding use of the Child Health Record by other health professionals...
Thus, a child's Green Book is very unlikely to contain all key health information about the child and therefore cannot and should not be relied upon by health professionals to collect complete, aecurate and update to date health record of the child.
.. it is not intended for use by héalth professionals as a way to disclose health information about a particular child to other health prafessionals.
In the circumstances where a MCH nurse makes a referral for a child or their parents to aitend a consultation with another health professional (such as a General Practitioner) the MCH nurse will, i most instances, generate a referral letter/document that is provided in hard copy to the family ta take along to the consultation with the health professional. This letter/documentation will ordinarily indludeé all of the key health information that the health professional is likely to need, including ‘the reasons for the referral by the MCH nurse, There is no expectation that the health professional will also review the child's Green Book in order to obtain the relevant information about why ihe child is being referred, 74
348, accept that the Green Book is not the intended, or preferred vehicle for sharing concerns about a child between health professionals or for apprising other health professionals of important
health information.
Information Sharing - General
“What are the options in terms of systems processes for health care providers responsible for the care of young infants and children io share information with other health care providers?”
350, Dr Gabriel replied:
“My role at the Department is, amongst other duties, to lead a state-wide reform of Victoria's Maternal and Child Health Services ineluding overseeing the update of program and service guidelines and standards for MCH Nurses.
As such, my knowledge of information sharing systems aiid processes for healih care providers is limited to those systents and processes available. to MCH Nurses,
To date, information shure between MCH nurses and other health prafessionals has been predominantly one-sided. MCH nurses refer many children(fumilies. (with consent of the parent) to General Practitioners or other health professionals (such as éarly parenting centres, mother-baby units and dental services) but rarely receive any ackndwledgement that a referral was received, or any information about how the referral was-actioned, or what was the outeame of the referral.
96 Leiter. from: Dr Anastasia Gabriel, 17 December 2015
, oo "Page 76 of 80
MCH nurses will generally identify a need or form an opinion based on assessment frameworks or clinical judgement that a referral to an external health professional is required. An MCH nurse would normally document their concerns or rationale for the referral in the database used by the local appropriate health professional and provide this referral to the family to then hand to the health professional. On rare o¢easions, the MCH nurse may phonéfemail the referred health professional to express concerns about a family/child.
This process is consistent with the Maternal and Child Health Service Program Standards 2009, that state that a referral froin MCH nurses to other health care professionals or commuinity services/agencies should include, at a minimum, the child’s nanie, date of birth, contact details, family details, the reason for the referral and any relevant health information. 77
“Do you believe current options for information sharing between health care practitioners caring for infants, such as doctors, maternal child health services and specialists are sufficient?
“As stated above, Iam not in @ position to comment on the sufficiency of the current options |
"for information sharing between health cave professionals caring for infants generally. | Jn regards to the sharing of information between MCH nurses and other health care professionals caring jor infants, it would be valuable for MCH nurses to receive a report or letter in reply from the health care professionals to whom they have referred a family or child, Collaboration and mutual communication. between MCH nurses and other health | professionals is important for the following reasons,
This is particularly important for MCH nurses because they are often the only health professionals to see a child and their family regularly over a lengthy period of time.’?*
Clearly systems of commiunicaiion should support the purposes she lists — in particular the purpose of ensuring that “ail health professionals involved in caring for, or supporting the child
or family are aware of any progress or changes to the health or development of a child or a
/ | |
parent.” To the extent that-they do not, they should be improved.
354, On the topic of information sharing | received a proposed recommendation from Moreland City Council. It related to the developmenit of databases where information in respect of contacts for
all services providers is established. The submission proposed:
27 Letter of Dr Anastasia Gabriel dated 17 December 2015 p 4 28 1 etter of Dr Anastasia Gabriel dated 17 December 2015 p 5
355,
“That there be established an electronic database accessible by maternal and child health and other service providers. That databasé ought act like a telephone hook of providers such that, with parental consent, a health care worker assisting the family can add their name to the list of workers assisting the family, That way ail those workers registered on the database as. working with that fantily became visible and contactable by telephone or email. The.database should include-an ability by any worker involved to notify all other service providers registered on the database if there is a change in a child's risk level.”?”
The submission noted that there is already in use “.,.by some Victorian Municipal Councils a website application connecting practitioners from focal services with comman clients within a
geographic area.
The submission encouraged me to recommend ™.,. that stakeholders, and particularly government finded stakeholders, involved in delivering maternal and child health services collaborate and consider joining and extending that database. or creating a similar database, in
respect of maternal and child health services.?™
A proposal of this nature was not directly canvassed in evidence, although | did invite the parties to consider the issue of inforrnation sharing. It is important 16 point out that there was no suggestion in this case: that the health professionals involyed were unaware of each other’s involvement. The problem was more that they were unaware of the content and outcomes of the actions of each other; the most stark example being the fact that Ms Monagle was not aware of
the bruising findings of Ms Kingston,
However there is merit in the proposal by the Moreland City Council. Medical practitionérs were unaware of the observations made by those who dealt with the A children before therm anc they did not have access to a shared or single medical record to assist them. Apart from the internal information within the Moreland MCH database, other practitioners following on were not in a position to access a single health record (shared database) to inform their knowledge and actions. Ms Monagle could have, but did not look, at Ms Kingston's note in the Moreland MCH database, but it may well have assisted other practitioners, dealing with the family after 30 March 2012, (when bruising was detected by Ms Kingston), to be aware of what she had seen and noted. Dr Zagarella saw the children on 10 April 2012, saw Ms A ont8 April 2012 with Ms Goodchild and Dr Dawson saw the family on 19 April 2012. A single health record, accessible by each of these practitioners al the point of their consultation with the family would have at least enabled them to see Ms Kingston’s note and to take it into account in
formulating thetr responses to {he presentations on the day.
298 Submission-on behalf of Moreland City Council, p 19 38° Submission on behalf of Moreland City Council, p 19
31 Submission on behalf of Moreland City Council, p 19
“Page 78 of 80
359,
I note a second recommendation from Moreland City Council in respect of the need to review privacy legislation in this context. ‘However there was no-eVidence in this case (hat practitioners believed they couldn’t share.information because of perceived privacy constraints. Arid it is not
open to conclude that better information sharing would necessarily have altered the outcome.
1 note also the information from Dr Gabriel of DET that information exchange is often one-sided and that MCH nurses often receive io infonnation on outcomes of referrals. I agree ihat a letter to referring MCH nurses with infonnation relating to. ihe. outcomes: would: be desirable.
However, again the issue in this case not about method of referral and feedback to the referring
health professional.
The development of a shared database, or a single health record, would undoubtedly be complex and expensive. It would involve policy and implementation/practical considerations — not the least of them being IT issues. In addition it cannot be concluded that a better sharing of information, let alone a single health record, would have made a difference to the outcorne in this case. However in my opinion the issue remains important. It was not strictly in the original scope of the inquest but emerged during the course of the inquest. Towards the end of the inquest, | invited the parties to consider it. I posed questions on the issue and Dr Gabriel responded as above (see paragraph 352). The Moreland City:Council made a submission on the
issue; however there was no direct evidence about current developments, if any, on the issue.
‘The investigation of the circumstances of | AA's death has crystallised information sharing ag an issue warranting a recommendation. The experience of the case can usefully inform policy making, For these reasons 1 will make a recommendation intended to focus attention on the issues of information sharing and, if feasible, to do so. by way of the development of a shared, single medical record applicable to infants/children, (and their mothers), being monitored and treated within the MCH system, and concurrently by other medical practitioners including GPs.
The recommendation is necessarily cautious. I assume that this is 4 dynamic and complex policy area and in making this recommendation | do not presume the feasibility of what is
recommended.
Pursnant 1o section 72(2) of the Coroners Act 2008, | make the following recommendation(s) connected with the death:
1 recommend that relevant government departments (including the Department of Education and Training and the Department of Health and.Human Services), in collaboration with the Municipal Association of Victoria and. other stakeholders involved in delivering Maternal.and Child Health
services, examine the feasibility of the creation of a shared data base, being in effect a single
health record, of the monitoring and treatment of infants and children passing through the Maternal and Child Health system in Victoria. The purposs of the database would be to enable those monitoring and treating the infant/child to inform themselves, in yeal time, of progress and/or-changés in the health or deyélopment of that infanit/child by accessing the full medical record to that point in time, Pursuant (o section 73(1) of the Cotoners Act 2008 ahd section 18 of the Open Courts Act 2013, I order that the following not be published on the internet:
Any material that identifies or tends to identify the deceased as the subject of this coronial investigation. ‘This ingludes the deceased naine and that of the parents and siblings.
T extend my condolences to the family of AA
{direct that-a copy of this finding be provided to the following: MrA C/- Mr Tom Ballantyne, Mautice Blackburn Lawyers Ms A CH. Dowling McGregor Pty Ltd Moreland City Council, C/- Mr Michael Regos, DLA Piper Royal Children’s Hospital, C/- Ms Jess Bayly, K & L Gates Dr Sam Zagarella, C/- Ms Lara Larking, TressCox Lawyers Ms Sally. Goodchild, C/- Ms Lara Larking, TrossCox Lawyers
Department Secretary, Department of Education and Training, C/- Ms Elena Totino, Children Families & Education Law Unit, Legal Division
Department Secretary, Department of Health and Human Services, C/- Ms Kirsty McIntyre, Legal Services Branch
Detective Senior Constable Jennifer Booth, Coroners Investigator Senior Sergeant Jenhette Brumby, Counsel Assisting
Professor Jeremy Oats, Consultative Council on Obstetric & Paediatrié Mortality and Marbidity
Signature:
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