Coroner's Court of Western Australia

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

Inquest into the Death of Baby BE (name suppressed)

Delivered on :23 May 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

Suppression Order 1

Suppression of the deceased’s name from publication and any evidence likely to lead to the child’s identification. The deceased is to be referred to as Baby BE.

Suppression Order 2

Suppression of the identification of Baby BE’s siblings from publication and any evidence likely to lead to their identification and/or the identification of Baby BE.

Suppression Order 3

Suppression of the identification of Baby BE’s parents and paternal grandparents from publication and any evidence to likely lead to their identification and/or the identification of Baby BE.

Summary : On 26 May 2019 Baby BE, who was five months’ old, died at Perth Children’s Hospital. She had been taken into the provisional care and protection of the CEO of the Department of Communities on 21 May 2019 so her death was a reportable death and an inquest was mandatory under the Coroners Act 1996 (WA) and the coroner was required to comment on her treatment, supervision and care.

Baby BE had been brought to Joondalup Health Campus (JHC) by her parents on 20 May 2019. She was found to have catastrophic brain injuries, spinal injuries, retinal haemorrhages and multiple fractures. It was suspected by medical staff that the injuries had been inflicted and were not accidental. Baby BE was transferred to Perth Children’s Hospital (PCH) for intensive medical care. Both parents were spoken to by health staff and they denied harming their daughter but could not provide any explanation as to how she sustained the injuries. Despite intensive medical care, she had suffered an unsurvivable brain injury and after brain death was declared, ventilation and support was ceased and her death was confirmed by a doctor.

After her death, Homicide Squad detectives commenced a homicide investigation into her death. The parents had been interviewed not long after their baby had been taken to hospital and they were later arrested and interviewed again. Neither parent made any admissions or indicated they had any knowledge as to how she had suffered her fatal injuries. They were both released without charge. The police investigation remained open and eventually the matter progressed to inquest.

The evidence led at the inquest established that Communities had been involved with Baby BE’s family from as early as December 2016 due to concerns about child neglect in relation to her three older siblings, as well as allegations of family violence. Following a failed termination in December 2018, Baby BE was born by caesarean section at KEMH on 27 December 2018. She was very premature, at 24+1 weeks’ gestation, and was cared for in the Paediatric Intensive Care Unit (PICU) as she had multiple complications of prematurity. Baby BE’s parents did not visit her regularly in hospital or engage with her in any meaningful way. A senior social worker at KEMH wrote to the parents in late January 2019 explaining why they needed to visit their newborn daughter. They never responded to the letter and the visits did not increase. On 6 February 2019, KEMH staff referred Baby BE’s case to Communities and a case was opened into possible child neglect. Concerns about possibly family violence were also raised.

Communities staff visited the family home on 21 February 2019 and noted the house appeared to be in a very poor state. Further visits were not reassuring. Two Signs of Safety meetings were held, during which the parents were encouraged to visit Baby BE more often and efforts were made to remove barriers to their visiting. The parents visited more regularly for a short time before visits ceased again. The mother complained the father was making it difficult for her to visit more often. She was asked whether she experienced domestic violence but she denied this was occurring.

On 2 April 2019, an MRI of Baby BE’s brain was undertaken. The scan was generally normal. On 4 April 2019, Communities informed that Baby BE was medically ready to be discharged. She was kept in hospital for a couple more days while the mother stayed in overnight to demonstrate appropriate mothercrafting and the family home could be inspected again. The mother demonstrated appropriate attachment to her baby and Baby BE was discharged home into her parents’ care on 9 April 2019 despite ongoing concerns about the family home and the family dynamic.

Visits to the family home by Communities staff and child health nurses were not reassuring as Baby BE was not gaining appropriate weight and the home environment remained dirty and in need of repair. On 6 May 2019, both a Communities support worker and a child health nurse became concerned about a suspicious bruise on Baby BE’s jawline and the child health nurse suspected the baby may have been shaken. She told the mother to take the baby urgently to JHC for medical assessment and advised Communities, but the mother did not comply with the request. She did take Baby BE to KEMH the next day for a routine paediatric review but did not mention the concerns raised the previous day. The paediatric registrar who examined Baby BE did not observe any concerning signs other than the issue of her weight, but she later indicated she would have done a different kind of examination if she had been aware of the abuse concerns. Medical evidence later established Baby BE had suffered multiple skeletal fractures and a brain injury around this time. The bruise was referred to as a ‘sentinel event’ that indicated something was wrong but it was not properly explored at that time.

Child health nurses continued to raise concerns and eventually on 14 May 2019 Communities made a plan to open a full safety investigation as well as requiring the family to move out of the family home for safety reasons. It had become apparent the home did not have running water and there were major electrical issues, including limited lighting and exposed live wires. A safe house was arranged and the family were encouraged to move there, although it took some time to convince them to move.

On 20 May 2019, Communities workers visited the family at the family home at around 4.00 pm. Baby BE appeared well at that time although the mother and three older children were unwell. The mother returned to the safe house with all four of her children shortly afterwards. The father remained at the family home doing work around the house. Later evidence reveals the mother left the house twice after returning home, once for about half an hour and a second time for around two hours. She returned to the safe house for the last time around 9.30 pm. The father returned to the safe house at 10.00 pm. The older children were in bed asleep at that time, so it was only the parents and Baby BE who were up and about.

Records show the family arrived at JHC around 1.00 am on21 May 2019. The mother took Baby BE inside the ED while the father and other children waited in the car. They were seen by a triage nurse at 1.06 am. It was not initially apparent that the baby was critically unwell, but after about an hour she began to have seizures and was immediately given treatment. Doctors quickly established that she was critically unwell and steps were taken to transfer her to PCH for specialist treatment.

Scans taken at PCH on 21 May 2019 showed Baby BE had suffered an acute severe brain injury in the hours before her presentation to hospital. Further testing showed she also had multiple healing fractures to her ribs, arms and legs that had occurred at least 7 days prior to her presentation and also a brain injury that had occurred at least two weeks prior to her presentation. All of the injuries were consistent with the baby being violently shaken, so taken together it revealed she had likely been violently shaken at least once around two weeks before 20 May 2019, and again on 20 May 2019. The medical experts expressed the opinion that the injuries could only have been inflicted by an adult, and the three older siblings did not have the strength to grip the baby and apply the force that was involved. The parents spoke to health staff and police in the following days. They confirmed they were the only adults who cared for Baby BE.

Accounts differ about what occurred in the hours between when Baby BE was seen by Communities at 4.00 pm on 20 May 2019 until they presented at JHC. The father always maintained he did not come home until around 10.00 pm. The mother suggested the father was home much earlier and gave very different timelines for events, which were not always consistent. Police obtained CCTV footage that corroborated the father’s timeline.

The father was later convicted of assaulting the mother in the months after Baby BE’s death, in the context of an argument about who had harmed Baby BE, as well as other things.

Both parents were summonsed to give evidence at the inquest. They both attended and were represented by counsel while they gave evidence. They both denied harming Baby BE and denied knowing who did cause the harm to their daughter. They did not challenge the medical evidence that it could not have been caused by one of their children and they accepted they were the only other people caring for Baby BE at the relevant time.

The Deputy State Coroner found that the evidence established that Baby BE had been violently shaken by an adult at least twice, once before 6 May 2019 and once on 20 May 2019, if not more. The second incident caused her to suffer catastrophic brain and neck injuries that led to her death. The Deputy State Coroner found that the cause of death was brain death complicating head and neck injury and that she died by way of homicide. The only people who could have caused the injuries were the mother and the father.

Based upon the objective evidence, and then considering the parents’ accounts, the evidence can be distilled down to either:

  • On the father’s account, about 20 minutes after he returned home at 10.00 pm the mother told him there was something wrong with Baby BE’s eyes and she wasn’t feeding well. He looked at her eyes and could see they were abnormal. The mother then went for a brief shower and not long after she returned, Baby BE began to show early signs of seizures. Both parents became concerned and eventually they woke up the other children and drove to JHC Emergency Department; or
  • On the mother’s account, she had been unwell all day so not long after the father got home (which she originally estimated as around 6.00 pm, but could not in fact have been before 10.00 pm), she went and had a long shower or bath. She left Baby BE in a cot in the lounge room with the father. When she returned, he was holding Baby BE. The mother took the baby and noticed there was something wrong with her eyes. The mother then tried feeding the baby but she wouldn’t take a bottle. She told the father something was wrong and wanted to go to hospital but he initially said Baby BE was fine and went to bed. She then woke him up and they drove Baby BE to JHC ED.

The Deputy State Coroner was unable to determine on the evidence before her to the requisite high standard, given the seriousness of the allegations, which parent caused the fatal injuries.

The Deputy State Coroner made comments that the Department of Communities missed a number of opportunities to intervene and protect Baby BE, prior to her suffering the injuries that led to her death. The Deputy State Coroner did not make any recommmendations.

Catch Words : Premature Baby : Brain death : Shaken Baby Syndrome : Homicide : Family Violence  Department of Communitites

Last updated: 7-Jun-2024

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