The death of a baby in Bendigo due to her mother’s amphetamine use during pregnancy has prompted a Coroner to urge the Department of Health and Human Services to review and improve early intervention services.

‘Baby W’ died after her mother gave birth to her at Bendigo Health in 2014. 

Coroner Caitlin English found the cause of death to be intrauterine pneumonia and meconium aspiration complicating intrauterine growth, caused by maternal amphetamine use. 

As part of a lengthy investigation into Baby W’s death – results of which were published recently – Coroner English found the most significant factors contributing to the death were the absence of antenatal care and Baby W’s mother’s drug use during pregnancy. 

In her findings, Coroner English detailed the difficulties health and child protection services had in contacting and engaging Baby W’s mother during her pregnancy and the complexities of a health system that, at the time, was restricted in the amount of confidential information that could be shared. 

The report stated Baby W’s mother failed to attend a number of appointments at Bendigo Health, which were organised by the Department of Health and Human Services Child Protection.

DHHS CP obtained a urine sample from Baby W’s mother in October 2013, which tested positive for amphetamine and methamphetamine.

Baby W’s mother had previously admitted to amphetamine use during early pregnancy. 

Despite this, and a series of DHHS CP home visits, Baby W’s mother’s first attendance to Bendigo Health was in late December, 2013.

The report stated Bendigo Health did not consider referring Baby W’s mother to a specialist pregnancy drug support service given the patient’s history of missing appointments, and concerns the hospital had over breaching confidentiality by involving other health professionals without her consent.

A Bendigo Health maternity service employee, quoted in the Coroner’s report, said the hospital’s primary focus was to “foster and maintain” contact with the mother in the interests of her and her unborn child. 

Coroner English said despite the challenging behaviours of Baby W’s mother and her lack of engagement, “there were several indicators for risk of harm to allow for the sharing of information and appropriate staff conferencing between DHHS CP, the Bendigo Health maternity services and the GP to ensure that relevant medical, mental health and psychological concerns were exchanged in order to ensure the safety of the unborn baby”.

The Children Legislation Amendment (Information Sharing) Bill 2018 passed through parliament in May. It allows a group of prescribed entities to share information to promote a child’s wellbeing or safety.

The investigation also included a report from the Medical Head of the Women’s Alcohol and Drug Service at the Royal Women’s hospital.

That report concluded 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, which focused 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 abuse during pregnancy,” Coroner English said.

The Coroner made a number of recommendations in her report, including; 

Coroner English said an improved focus on early intervention will “help improve pregnancy outcomes and prevent the severity of parenting difficulties”.

A DHHS spokesperson said the department extends its condolences to the family of Baby W.

“The department takes very seriously its obligations under the Coroners Act, and provides a considered response to each recommendation made to it within required statutory time frames," he said.

The department must provide a written response within three months of receiving the recommendations of a Coroner.

The response should include a statement of actions taken, or to be taken, in relation to the recommendations.

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