Demographics
female
Coroner
Coroner Caitlin English
Date of death
2014-01-13
Finding date
2018-10-05
Cause of death
Intrauterine pneumonia and meconium aspiration complicating intrauterine growth restriction in the setting of maternal amphetamine use
AI-generated summary
Baby W was born at 37+5 weeks in an ambulance and died at Bendigo Hospital from intrauterine pneumonia and meconium aspiration secondary to intrauterine growth restriction related to maternal amphetamine use. The mother had known substance abuse, prior child protection involvement, and tested positive for amphetamine during pregnancy (October and December 2013), yet did not engage with maternity services until 20 December, just 3 weeks before delivery. Critical failures included: absence of systematic substance use screening during early pregnancy, lack of specialist addiction medicine consultation despite known daily amphetamine use, non-attendance at appointments without assertive follow-up, poor information-sharing between child protection and maternity services due to confidentiality barriers, and absence of supportive outreach when the mother disengaged. Clinicians prioritised maintaining engagement over providing specialist drug support, fearing referral might deter the mother from care. Better outcomes required: early risk assessment, mandatory referral to specialist pregnancy drug services, proactive home outreach, information-sharing protocols for at-risk pregnancies, and multidisciplinary case conferencing combining child protection, obstetrics, and addiction medicine.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
OF VICTORIA AT MELBOURNE Court Reference: COR 2014 0201
FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008
Findings of: Caitlin English, Coroner
Deceased: Baby W
Date of birth: 12 January 2014
Date of death: 13 January 2014
Cause of death: 1(a) Intrauterine pneumonia and meconium aspiration
complicating intrauterine growth in the setting of
maternal amphetamine use
Place of death: Bendigo Health, Maternity Ward Room 16
Introduction
spontaneous labour at 9,00pm at 37+5 weeks gestation.
meconium, had minimal respiratory effort and appeared cold and pale.
Baby W died in her mother’s arms the following morning on 13 January 2014 at
6.21am.
The coronial investigation
Baby W’s death was reported to the Coroner as it was unexpected and fell within the definition of a reportable death in the Coroners Act (2008).
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances.
Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish
the facts, not to cast blame or determine criminal or civil liability .
developing prevention-focused recommendations.
Royal Women’s Hospital. A medical investigator’s report was prepared by Dr
Heinrich Bouwer, the forensic pathologist who examined Baby W. The materials also include a toxicology report and a neuropathology report by Dr Linda Iles. Medical records were also obtained from Bendigo Health, Tristar Medical Group, Eaglehawk Medical Group and Ambulance Victoria (AV). Baby W’s mother was asked but did
not wish to provide a statement for the investigation.
I have based this finding on the evidence contained during the course of the investigation, namely the above-mentioned statements, exert reports and medical records. In the coronial jurisdiction facts must be established to the standard of proof
which is the balance of probabilities.’
I take into account section 8 of the Coroners Act 2008, particularly section 8(€) and the public. interest in protecting the personal information of Baby W’s mother, and have redacted her and Baby W’s identities for distributing this Finding and publishing it on the Internet.
Background — medical engagement during pregnancy
Baby W’s mother was aged 23 and pregnant with her second child. Her pregnancy care when she was pregnant with her eldest child in 2008 was shared between Dr
Patrick Duane and Bendigo Health.
Baby W’s mother had a medical history which included substance abuse of methamphetamine. She had also suffered from anxiety and depression since 2007 and
had been engaged with Bendigo Child & Adolescent Mental Health Service.
On 9 July 2013 Baby W’s mother had an appointment with Dr Ismail at Tristar General Medical Practice in Eaglehawk and her second pregnancy was confirmed by obstetric ultrasound. At that time, she was 11 weeks pregnant with a due date of 28
January 2014.
The pregnancy results were copied to Dr Duane at Eaglehawk Medical Group. Baby W’s mother did not attend appointments on 11 June, 18 July and 15 August 2013.
1 This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336, The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
In September 2013 Baby W’s mother transferred her medical care to Tristar General Medical Practice from Eaglehawk Medical Group and attended an appointment on 11 September 2013. She had a morphology ultrasound on 12 September 2013 at 20 weeks gestation which was normal. Baby W’s mother did not attend scheduled
appointments on 16 September and 25 November 2013.
Baby W’s mother re-engaged with Dr Duane at Eaglehawk Medical Group on 22 November 2013 at 30 weeks gestation. She denied active drug use. She did not attend
an appointment on 6 December 2013.
Baby ‘W’s mother subsequently attended an appointment with Dr Duane on 20 December 2013. A Group B Streptococcus (GBS) swab was taken (the results of which were negative), blood tests arranged, and an obstetric ultrasound showed
acceptable foetal growth.
Dr Duane referred Baby W’s mother to Bendigo Health the same day, and she attended in the afternoon of 20 December 2013 at 3443 weeks gestation, which was
her first direct contact with an obstetric service during pregnancy.
During Baby W’s mother’s ‘booking in’ appointment at Bendigo Health, she reported periodic attendances at the GP, and using amphetamines daily throughout pregnancy although she gave up for a period in July.” She declined a referral to the Maternal
Services Program.
Baby W’s mother did not attend an ante-natal appointment at Bendigo Health on 23
December 2013, and her mother rang and explained she was unwell.
On 24 December 2013 she attended for a CTG which monitors foetal heart rate, which
was normal, and she was assessed by an obstetrician prior to leaving the clinic.
On 30 December 2013 Baby W’s mother did not attend an ante-natal appointment, however she attended on 2 January 2014. A further CTG was normal and she was provided with a pathology slip to test for gestational diabetes.
Baby W’s mother did not attend an appointment on 9 January 2014.
2 Progress note dated 20 November 2013, Bendigo Health Medical Records.
Circumstances in which the death occurred
23). On 12 January 2014 at approximately 9.00pm, Baby W’s mother went into
spontaneous labour at 37+5 weeks gestation. An ambulance was called at 9.27pm.
10.37pm. The liquor was noted to be meconium stained.
without assistance at 10.55pm.
Bendigo Hospital.
27, Her Apgar scores were 5 at | minute and 3 at 5 minutes.’ According to the AV Electronic Patient Care Report the ambulance departed at 11.01pm and Baby W and her mother were transported to the Bendigo Health Emergency Department (ED).*
Her cord was clamped and cut and she was moved to a resuscitation cot.
Cardiopulmonary Resuscitation (CPR) was commenced and an intraosseous needle was inserted. Adrenaline, aramine and normal saline fluid boluses were administered.” Baby W was intubated and ventilated, and umbilical venous and arterial lines were inserted by the paediatrician attending the resuscitation. Thick meconium was
aspirated from the endotracheal tube.
Py
Apgar scores are a measure of a neonate’s physical state after birth (specifically heart rate, colour, respiratory effort, response to stimulation and tone). Scores range from 0 (poor condition) to 10 (good condition). A score of 7 or higher is considered normal and a score of 3 or less is considered low. A score of 3 or less at five minutes of life and beyond is abnormal and associated with adverse neurological outcomes and increasing mortality.
The AV times do not match the Bendigo Hospital records with the first blood gas sample recorded at 10.45pm on 12 January 2014.
A Code Blue alerts the team of medical and nursing staff skilled in neonatal resuscitation.
This weight is on the 10" percentile according to World Health Organization growth charts.
Adrenaline increases the strength and frequency of heart contractions and increases blood pressure. Aramine (metaraminol) is a vasoconstrictor medication that supports circulation by increasing blood pressure.
a anw
Baby W was transfused with red blood cells, fresh frozen plasma and cryoprecipitate to correct her severe anaemia and clotting abnormality. Intravenous antibiotics were
given to treat for presumed sepsis.
Baby W appeared to stabilise but subsequently deteriorated. Her heart rate periodically dropped to 60 beats per minute and she intermittently required cardiac massage to maintain circulation. A chest x-ray identified a right sided pneumothorax.®
A right intercostal catheter was inserted to relieve this.
Full resuscitation efforts continued for over six hours and were unable to stabilise Baby W. A decision was made to palliate Baby W, as she was unlikely to survive transportation to Melbourne. She was extubated at 5.55am and remained in her mother’s arms until she was declared deceased at 6.21am on 13 January 2014. The
DHHS Child Protection service was notified of the death.
Post mortem examination
On 17 January 2014, Forensic Pathologist Dr Heinrich Bouwer at the Victorian Institute of Forensic Medicine, conducted a post mortem examination. Dr Bouwer completed a report, dated 11 July 2014 in which he formulated the cause of death as ‘I(a) Intrauterine pneumonia and meconium aspiration complicating intrauterine
growth restriction in the setting of maternal amphetamine use’.?
T accept Dr Bouwer’s opinion as to the medical cause of death.
Baby W’s lungs revealed widespread atelectasis, focal intra-alveolar haemorrhage and
meconium in the distal airways with an early acute neutrophilic infiltrate.
8 A pneumothorax is caused by the escape of air into the space around the lung within the thorax, which causes
the lung to collapse. The pocket of air may progressively inflate and compress the heart and opposite lung, leading to circulatory collapse and respiratory failure. An intercostal catheter is a plastic catheter inserted between the ribs to remove the air that has collected.
9 Intrauterine pneumonia refers to inhalation of infected amniotic fluid with subsequent establishment of an infection in the lung tissue.
metoclopramide and lignocaine.'°
Chronology of Department of Health & Human Services (DHHS) and Bendigo Health
involvement
| DHHS Child Protection (CP) received a report on 8 April 2013 in relation to Baby W’s mother’s eldest daughter. The report alleged that Baby W’s mother was using methamphetamine and Valium!! to excess, rendering her unable to care for her eldest daughter. CP sought a protection order in the Bendigo Children's Court which was granted on 27 June 2013.”
On 22 August 2013, Baby W’s mother advised CP, during a home visit, that she was 20 weeks pregnant. Baby W’s mother did not comply with the request to complete a
supervised urine drug test within 24 hours.
provided by Baby W’s mother on 5 October 2013.
as possible and would be considered for care by a caseload midwife through the
10 Methyl amphetamine and amphetamine indicate maternal use and would not have been given during the resuscitation. Metoclopramide is an antiemetic and desmethylvenlafaxine is an antidepressant metabolite.
These were likely from maternal use as they are not used in neonatal resuscitation.
11 The trade name for diazepam, a benzodiazepine.
12 Statement of Veronica Martin, DHHS, dated 20 October 2015.
13 See Dorevitch Pathology Report dated 8 October 2013, Child Protection File. Both results showed levels greater than 2000ug/litre.
14 Mg Rosenbauer, a social worker, is also a registered nurse and manages the Bendigo Health maternal support program.
15 ‘The date of this advice is unknown, but according Veronica Martin’s statement it occurred following the receipt on 8 October 2013 of the results of the positive drug screen, so possibly 9 October 2013.
Bendigo Health ‘Mamta Program’,'® where she would see the same clinician each
visit who would monitor and support her pregnancy."
and urine screens which detected her amphetamine use.
unborn child and again requested her to contact the Bendigo Health maternity service.
On 18 October 2013, CP contacted Bendigo Health and made a maternity appointment for Baby W’s mother for that day and the following day, in case she was unable to attend. Baby W’s mother did not attend either appointment.
On 19 October 2013, CP: formally advised Bendigo Health maternity services in writing that CP held significant concerns for the health and wellbeing of Baby W’s mother's unborn child.!? However, according to Bendigo Health the first contact by DHHS was on 25 November 2013, when they received an email from CP outlining
their concerns.
16 Mamta is a caseload model of midwifery care that offers continuity of care throughout pregnancy, birth and the postnatal period. This model of care is offered to women across all risk levels in collaboration with the medical team. Midwives work in small teams of two or three to ensure women have an opportunity to get to know their carer. Women who are booked into the Mamta model will be allocated to a midwife and other team members will be called as back-up midwives.
17 A more appropriate model of care was the Complex Pregnancy Care program.
18 Children, Youth and Families Act 2005 Section 29 states: ‘... a person may make a report to the Secretary, before the birth of a child, if the person has a significant concern for the wellbeing of the child after his or her birth.’ However, if the mother is not willing to co-operate with Child Protection, she cannot be compelled to accept advice and assistance or services to which she is referred. Child Protection may convene a case conference with the relevant professionals to determine the process for re-reporting closer to or at the time of the child’s birth.
19 Statement of Veronica Martin, DHHS, dated 20 October 2015.
On 24 November 2013, Baby W’s mother was asked to complete a further urine drug test. The results, received on 9 December 2013, were positive for amphetamine and
oxazepam.”?
On 29 November 2013 and 13 December 2013, Bendigo Health Maternity Service program report emailing DHHS informing them that Baby W’s mother was still not booked in at Bendigo Health. The maternity program requested a letter from DHHS for the Bendigo Health medical record in case Baby W’s mother presented in labour
or birthed without having previously made contact with Bendigo Health.
On 18 December 2013 CP made two appointments from Baby W’s mother to attend an appointment at the Women’s Health Centre in Bendigo on 18 and 19 December
On 18 December 2013 CP conducted a home visit to Baby W’s mother.
On 19 December 2013 CP wrote to Bendigo Health maternity services advising of the unborn report and that a Pre-Birth case conference ‘will be organised in the very near
future.’?!
The first attendance by Baby W’s mother at Bendigo Hospital was on 20 December 2013.
On 27 December 2013 Baby W’s mother advised CP she had attended an ante-natal appointment at Bendigo Health Maternity Service. She was invited to attend a case plan meeting for her eldest daughter on 30 December 2013 however she did not attend. CP attempted to contact Baby W’s mother by telephone and text on 31 December 2013, 6 January 2014 and on 7 January 2014. Baby W’s mother contacted CP on 8 January advising she and the baby were well. CP arranged for a home visit on
14 January 2014.
There is a discrepancy in the evidence as to when CP contacted Bendigo Health. CP appears to have made telephone calls during in October 2013 and indeed spoke to
Monique Rosenbauer and scheduled appointments on Baby W’s mother’s behalf.
20 See Case Note dated 14 January 2014, Child Protection File.
21 Letter from Penny Larke, Advanced Child Protection Practitioner, DHHS, to Monique Rosenbauer, Bendigo Health, dated 19 December 2013.
However Bendigo Health states the first contact from CP was by email on 25
November 2013 when they received an email outlining CP concerns.
Review of DHHS and Bendigo Health involvement
53%
DHHS was asked to advise why the ‘Pre-birth case conference’ did not occur. After
reviewing the electronic records, DHHS advised
‘there is no case note or indication as to why a pre-birth case conference did not
proceed as foreshadowed.”
DHHS was also asked if CP complied with DHHS practice and procedure regarding the unborn report made 9 October 2013. DHHS advised:
‘In the absence of the co-operation or consent of [Baby W's mother], there was little the Department could do prior to [Baby W]’s birth other than what was undertaken
as described by Ms Martin in her statement.
_..Whilst the child is in utero, an unborn child report cannot be classified as a protective intervention report and an investigation cannot be undertaken until after
the child’s birth.
...Practice guidelines at the time included the need for consent from the mother as the mother’s involvement is voluntary, sharing information with reporters, pre-birth case conferences, and the engagement of a practice leader to support decision making. In reviewing the file, it appears that an unborn report was registered and that there was contact with [Baby W’s mother] to attempt to facilitate her engagement in ante-natal care. [Baby W’s mother] indicated she was receiving support from her general practitioner and advised the Department that she had attended an ante-natal
appointment...’
The first attendance by Baby W’s mother to Bendigo Health was on 20 December 2013.
2 Statement of Kim Grindlay, DHHS, dated 11 July 2018 23 Statement of Kim Grindlay, DHHS, dated 11 July 2018
Ms Rosenbauer commented the focus was on the pregnancy, therefore Bendigo Health did not give active consideration to referring or consulting with a specialist
pregnancy drug support service. Further Ms Rosenbauer commented,
‘Given the difficulty Bendigo Health staff encountered with the patient's erratic compliance with keeping her appointments and her decision to decline the offer of follow up support from the MSP (Maternity Service Program), any action by Bendigo Health staff to encourage the patient to accept a referral to a specialist drug support agency would be likely to threaten the ongoing engagement of the patient with Bendigo Health. As noted earlier, Bendigo Health was anxious to facilitate that
ongoing engagement in the interests of both the patient and her unborn child.
In these circumstances, Bendigo Health did not give active consideration to referring
the patient to a specialist pregnancy drug support service.
...the primary focus of Bendigo Health was to foster and maintain an ongoing
engagement between the patient and Bendigo Health in the very short time available
following the patient's initial contact, Obtaining the consent and active cooperation
of the patient to participation in a case conference was not the primary focus of
Bendigo Health.’
Ms Rosenbauer commented that, given there was no specialist pregnancy drug support service available in Bendigo,” along with the imminent Christmas holiday break, it was highly unlikely that an appointment with a specialist drug support service would be available if Baby W’s mother had elected to accept an offer of a
referral. Further, a referral would have required patient consent and co-operation.
Bendigo Health noted the potential for breaching confidentiality by involving other health professionals in Baby W’s mother’s case without her consent. The Children, Youth and Families Act 2005 imposes limitations particularly regarding information
sharing amongst health professionals in the absence of maternal consent.
24 Statement of Monique Rosenbauer dated 4 May 2015.
25 The nearest specialist pregnancy drug support services were physically located in Melbourne at The Royal Women’s Hospital, Mercy Hospital for Women and Monash Medical Centre.
Bendigo Health noted the situation regarding the exchange of information to be unsatisfactory and a significant impediment to implementation of early intervention
initiatives, and supported amendment of the Act.
DHHS agreed with Bendigo Health that the law generally does not allow most agencies to share information with each other about vulnerable children the parents’
(and if old enough, the child’s) consent.
DHHS has advised that the Children Legislation Amendment (tefovmation Sharing) Act 2018 will allow a group of prescribed entities to share information to promote a child’s wellbeing or safety. Organisations that provide services to parents, children and families will be able to share information with each other proactively or on request in order to promote a child’s wellbeing or safety or manage a family violence risk. Reforms like this one will enable the types of information sharing recommended
by Bendigo Health.”
With respect to the unborn report, significant limitations exist within the current scope for DHHS involvement in the circumstance of an unborn report. The mother in an
‘unborn report’ cannot be compelled to comply with advice or referral to services.
Many and various steps were taken by CP to ascertain more information about the professionals and services engaged with Baby W’s mother up and to including the time of Baby W’s birth however all engagement by Baby W’s mother was voluntary
and not statutorily mandated.
DHHS advises that the DHHS Child Protection Manual in relation to unborn reports was updated on 23 November 2017 however the current practices and procedures in
relation to unborn reports are substantially similar to those that were in place in 2013.
Substance use and pregnancy
The most significant contributory factors to Baby W’s death were the absence of ante-
natal care and Baby W’s mother’s drug use during pregnancy.
Methamphetamine use is an emerging problem in rural and metropolitan Victoria,
with evidence of increasing purity, fatal overdose and arrests for possession and
26 Statement of Mick Naughton, Director, Children and Families Policy, DHHS, dated 16 February 2018.
trafficking in the last decade.?” The number of deaths in Australia associated with methamphetamine use doubled between 2009 and 2015. Toxicity was the most frequent cause of death, but deaths by suicide, accident and natural disease made up
more than half of the deaths in this period.”*
emergency departments.”
may be at risk of intoxication and withdrawal after delivery.>!
and child, For these reasons, broad psychosocial assessment is necessary to help
27 Penington Institute, ‘Impacts of Methamphetamine in Victoria: A community assessment’. Report for the Victorian Department of Health, June 2014. Accessed 19 November 2014. Available online from www.penington.org.au.
28 Shane Darke, Sharlene Kaye and Johan Duflou, ‘Rates, characteristics and circumstances of methamphetamine-related death in Australia: a national 7-year-study’ (2017) 112(12) Addiction 2191.
29 Penington Institute, ‘Impacts of Methamphetamine in Victoria: A community assessment’. Report for the Victorian Department of Health, June 2014. Accessed 19 November 2014. Available online from www.penington.org.au.
30 Chang G. Overview of illicit drug use in pregnant women. UpToDate. Last updated 17 October 2014.
Accessed 19 November 2014.
31 Jenner L and Lee N. Treatment Approaches for Users of Methamphetamine: A Practical Guide for Frontline Workers. Australian Government Department of Health and Ageing, Canberra, 2008. Accessed 19 November 2014. Available online from http://www.nationaldrugstrategy.gov.au/ internet/drugstrategy/Publishing.nsf/content/8D2E28 1FAC2346BBC A25764D007D2D3A/$File/tremeth.pdf
322 The RANZCOG website provides a list of clinical guideline statements. The advice in this guideline has been formally endorsed by RANZCOG, after it has undergone a formal endorsement process.
understand the reasons for the woman's substance use for the purpose of addressing
these issues.?
Opportunities for prevention
Baby W’s mother presented with challenging behaviours which related to substance use in pregnancy. She had a lack of engagement in attending regular pregnancy reviews and poor compliance with the re scheduling of pregnancy appointments.
Despite this, there were several indicators for risk of harm to allow for the sharing of information and appropriate staff conferencing between DHHS child protection, the Bendigo Health maternity services and the GP to ensure that relevant medical, mental health and psychosocial concerns were exchanged in order to ensure the safety of the
unborn baby.**
Bendigo Health did not seek advice or consult with specialist alcohol and drug pregnancy services due to concerns with the need for consent to share information, their tenuous relationship with Baby W’s mother given her reluctance to engage and the potential to adversely impact their engagement with her. In addition, given the proximity to Christmas, it was assumed an appointment with a specialist service in
Melbourne would not be available.
Baby W’s mother was already referred to Child Protection and a protection application had been granted with respect to her eldest daughter in respect of Baby
W’s mother’s methamphetamine and diazepam use.
An ‘unborn report’ pursuant to section 29 of the Children Youth & Families Act 2005
was made on 9 October 2013.
An expert report was obtained from Dr Yvonne Bonomo, Medical Head of the Women’s Alcohol and Drug Service (WADS) at the Royal Women’s Hospital to
address opportunities for systemic improvements
33 Minozzi S. Psychosocial treatments for drugs and alcohol abusing adolescents. Cochrane Database of Systematic Reviews. 2011 Issue 3.
Royal Australian College of Obstetricians and Gynaecologists. Clinical Practice Guideline ‘Substance Use in Pregnancy.’ Endorsed July 2011. Accessed 23 December 2014.
34 Under the Children, Youth and Families Act 2005 reports and referral to Community Child and family Services (Child FIRST) can be made during the pregnancy with an intervention plan developed.
In her report she noted much of the onus to engage in antenatal care was put on Baby W’s mother and referred to a punitive rather than supportive framework used which
focussed on urine drug screens.
The death of Baby W presents several opportunities for reviewing and further developing current national,” state,° and professional body’ resources to assist those health professionals and services associated with antenatal care and substance use
during pregnancy.
In particular, those working in a rural setting could benefit from education and the support provided by the state-wide services such as the Women’s Alcohol and Drug Service (WADS).*8 The WADS team advocate that comprehensive support from a multidisciplinary team is critical in reducing the harms associated with alcohol and drug use in pregnancy. The service is available for telephone consultation and, in
particular, an obstetrician is available for case discussion 24 hours a day.
In her report, Dr Bonomo included current best practice in the care of pregnant women with past or current substance use and in particular polydrug use and
methamphetamines.
The death of Baby W presents an opportunity to promote systematic risk assessment
of substance use by pregnant women and individualised collaborative care planning.
Dr Bonono and Dr Lynch from the Women’s Alcohol and Drug Service at the Royal Women’s Hospital also gave advice during the course of the coronial investigation regarding the formulation of recommendations to improve the provision of ante-natal
care for mothers who use illicit substances during pregnancy.
35 New South Wales Department of Health, ‘National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn’ (2006).
36 Relevant Victorian Department of Human Services guidelines.
37 The Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
38 WADS is the only state-wide drug and alcohol service, providing specialist clinical services and professional
access to a 24-hour obstetric service, and utilise a multidisciplinary team approach to advance women’s health and well-being and the medical needs of their infants. WADS is located at The Royal Women’s Hospital in Melbourne.
Finding
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations
connected with the death:
To Safer Care Victoria
That Safer Care Victoria Maternity and Newborn Clinical network replicate the ‘Substance Use during Pregnancy! information®® currently located in the electronic neonatal handbook within the electronic Maternity handbook. The ‘Substance Use during Pregnancy’ information highlights the necessity of assertive follow up by primary care providers,*° which includes checking on referrals made on behalf of pregnant women using substances to establish the woman attended the maternity service for pregnancy care. The ‘Substance Use during Pregnancy’ information includes what to do when a woman has not attended their appointments or pregnancy
care.
To the Victorian Department of Health and Human Services
2s
That the Victorian Department of Health and Human Services articulates referral pathways to suitable home visitor services or outreach workers to follow up with the pregnant woman at home or wherever she might be found when a she fails to attend pregnancy care. The 'Substance Use during Pregnancy’ information includes direction on how and when to share information about high risk individuals to relevant agencies or organisations. This includes an explanation to the woman when a consultation with
a specialist service or other support worker is required.
39 The Victorian Department of Health and Human Services. ‘Neonatal eHandbook’. 2016. Accessed on 26
February 2018 at www2.health.vic.gov.au.
40 The initial point of contact for a substance using pregnant woman may include GPs, child protection, alcohol
and drug workers, psychiatrists, midwives and allied health workers.
That the Victorian Department of Health and Human Services undertake research to establish the current rate and timing of risk screening for substance use by pregnant
women.
That the Victorian Department of Health and Human Services support maternity services in educating staff on how to frame the risk enquiry questions for substance
use and the appropriate response upon disclosure.
That the Victorian Department of Health and Human Services undertake a review to identify opportunities in program delivery to improve early intervention by outreach services for women who are pregnant and use substances. This focus on early
intervention will help to improve pregnancy outcomes and prevent the severity of
parenting difficulties.
To the Royal Australian College of General Practitioners
link to the 'Substance Use during Pregnancy’ information.
I direct this finding be published on the Internet.
I direct that a copy of this finding be provided to the following:
Senior next of kin
Dr Patrick Duane, Eaglehawk Medical Group
Tristar General Medical Practice
Ambulance Victoria
Mr Jack Squires, Bendigo Health
Royal Australian and New Zealand College of Obstetricians and Gynaecologists Dr Theresa Lynch, Royal Women’s Hospital
Department of Health and Human Services Maternity & Newborn Services
Adjunct Professor Tanya Farrell, Chair, Consultative Council on Obstetric and Paediatric
Mortality and Morbidity
Constable Bianca Cola, Bendigo Uniform, Coroner’s Investigator, Victoria Police
Signature:
CAITLIN ENGLISH CORONER Date: 5 October 2018
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