A coroner has found multiple systemic issues in the lead-up to the death of a 12-day-old infant living with her mother in custody at Melbourne's maximum security women's prison.
Baby A spent a week in special care at Sunshine Hospital after her birth on August 6, 2018, before being discharged with her mother to participate in the Dame Phyllis Frost Centre's mother and child program.
But within 24 hours of her release the infant was back in hospital because of a decline in weight and jaundice.
Baby A and her mother were released again at midday on August 17, but at 5.30am the following day the mother woke to find Baby A dead in her cot.
Her death was attributed to SIDS Category II - the unexplained death of an infant younger than 21 days.
Coroner John Olle was critical of systemic issues he found in connection to the death of Baby A, but was unable to find that her death was preventable.
"In all the circumstances, Baby A's mother was the embodiment of a first-time mother, whose capacity to meet the challenges of a vulnerable baby demanded dedicated maternal support," he said.
"I consider the most significant omission identified in my investigation is the failure to ensure Baby A's mother received 24 hour dedicated maternal support in the period following the discharges of Baby A from hospital to DPFC."
He made a series of recommendations including that DPFC consider having an attending neonatologist or midwife on-site whenever there is an infant present.
He also recommended Victoria's Health Department introduce a NSW-style multi-disciplinary approach to discharge, so if any healthcare practitioner holds concerns about the discharge of a baby, having regard to the environment they'd be discharged into, the baby is not to be discharged.
Mr Olle noted Corrections Victoria officials had the power to overturn their approval of Baby A and her mother's participation in the prison's maternal-child program, and that doctors had the power to keep the infant in hospital.
"Baby A's mother's desire to remain with Baby A was normal and natural, however any such desire should not have been given primacy over the needs of Baby A," he said, adding that those needs were beyond what the mother could reasonably provide.
The coroner also pointed to evidence that Baby A's mother was distressed at possible separation from her baby and resisted advice about safe sleeping practices, preferring to hold her baby.
It was suggested Baby A's mother may have fallen asleep during an early morning feed and put the baby back in her cot in the belief she was just sleeping.
He expressed dismay at evidence several mothers in the mother and child program were regularly co-sleeping with their babies.
A decade ago he made findings into the deaths of 33 infants as a result of co-sleeping, leading to uniform education about the inherent dangers of the practice.
He urged parents to consider asking for help if and when they needed it to avoid endangering their babies.
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