Warning signs about a teenage father who killed his baby son in Bunbury Hospital were not “properly heeded” by some of the government authorities involved, a WA coroner has found.
Coroner Sarah Linton made the comment in her findings into the death of the 25-day-old child, known as Baby L, whose head was bashed against a doorframe or a wall of the hospital, when he was left alone in a room with his 15-year-old father for only minutes in February 2014.
The father, known as LCM, pleaded guilty to unlawfully killing the baby and was originally sentenced in the Children’s Court to 10 years in detention.
However, the sentenced was later reduced to seven years after the Court of Appeal found the teenager had foetal alcohol spectrum disorder, which contributed to the offence.
Baby’s death ‘shocked’ WA
An inquest into the death was conducted in Bunbury over three days last year and today Ms Linton released her findings in which she described the case as “an event that shocked the Western Australian public” and was “deeply traumatic” for all those involved.
The inquest heard that at the time of the baby’s death, LCM was under the care of the Department for Child Protection and Family Support because of his dysfunctional and traumatic upbringing.
He had a history of substance abuse, violence and crime, and his relationship with the baby’s 16-year-old mother was suspected of being marred by domestic violence.
Because of all those factors, the department was heavily involved in planning for the care and safety of the baby, who was born six weeks premature in January 2014.
Baby deemed safe, despite ‘Code Black’ incident
It was decided at the time “there was insufficient evidence” to remove the baby from his parents, and that instead he should be eventually allowed to go home with them.
Ms Linton said that was despite a so-called “Code Black” incident at the hospital 15 days before the baby’s death, in which LCM was reported as being aggressive and violent towards CTB (his partner) and/or his mother.
It led to LCM being banned from the maternity ward, but he was allowed to resume visits again three days later after his partner and their families told the authorities they were unhappy with the situation.
Ms Linton said that in the days before the baby’s death, there were a few incidents which in hindsight “might have provided clues that LCM’s ability to cope was decreasing, but it was either not apparent to the nursing staff at the time or they minimised it as they did not want to cause trouble for the young couple”.
The incidents included a midwife seeing LCM “irritated” and “jiggling” the baby, who was also observed to have a cut to his mouth after LCM tried to feed him with a bottle.
However, the incidents were not documented and plans were made for the baby to be discharged with a note being made that both parents were “caring for Baby L well … and were enjoying their time learning about caring for [him]”.
Two days later the baby’s mother returned to the room where LCM had been left alone with the baby for between three and 10 minutes, and found the child pale and not breathing.
He was transferred to Princess Margaret Hospital but died nine days later.
A post-mortem examination found he had suffered two skull fractures which caused severe brain injuries.
Warning signs ‘not properly heeded’
Ms Linton said the “catastrophic events” on the day that the baby was injured “could not have easily been predicted”.
“Nevertheless, there were warning signs that were not properly heeded by those involved, largely due to a lack of real understanding and knowledge about LCM and his increasing violence and lack of ability to regulate his emotions.”
She said some of this information was withheld by the families of LCM and his partner, while other information was missed due to problems with communication between various government agencies and staff taking leave.
“There were missed opportunities by the department to prioritise Baby L’s safety and wellbeing as a result,” she said.
Ms Linton said the death emphasised the need for early pre-birth planning in cases where an unborn baby may be at risk, which she said would allow all those involved to put in place proper safety networks.
She noted there had been a number of inquiries and reviews into the baby’s “tragic death” which had led to various changes being implemented and therefore she would not make any further recommendations.
She also noted that it was apparent at the inquest that the death had “deeply traumatised” many of the workers who were involved in the case, saying she had no doubt that in future they will take a “more precautionary approach.”