A coroner says insufficiencies in Victoria's maternal health services in the lead-up to a mentally unwell mother killing of her nine-week-old baby need to be addressed.
Melissa Arbuckle was in the depths of severe postpartum depression and psychosis when she laid her nine-week-old daughter Lily on railway tracks at Upwey in July 2021.
Arbuckle had been taking her daughter for a walk in a pram when she began searching for train speeds and timetables near her home, the court was told.
She messaged her husband saying the girl was unsettled before placing Lily on train tracks and lying down alongside her.
They were both struck by a train.
Lily died after being airlifted to hospital, while Arbuckle survived with fractures and internal bleeding.
An investigation into Lily's death by State Coroner John Cain found key medical staff failed to adequately respond to Arbuckle's repeated cries for help.
Judge Cain said numerous steps were not actioned by the Maternal Child Health (MCH) nurses engaged with Arbuckle after she scored highly on a depression screening tool for new mums.
Because of that, Judge Cain said, Arbuckle wasn't asked about the risk she posed to Lily, nor engaged with enhanced services or additional supports.
Her high score should have meant she was referred to her GP for a mental health review and an enhanced MCH program.
"I am particularly concerned given that this was the second time that Melissa had made reference to experiencing difficulties with her mental health and wellbeing and had made comments, at an unknown date, to suggest that further inquiry regarding her risk to Lily was warranted," Judge Cain said.
The coroners court heard MCH nurses made five failed attempts to contact Arbuckle in the week before Lily's death, but did not request a police welfare check because she wasn't part of the enhanced program.
If she had been part of the enhanced program, the unanswered calls would have triggered an escalated response, according to the Yarra Ranges Council MCH nurse co-ordinator.
The coroner handed down a suite of recommendations to reform MCH care, including a focus on infant safety and that supervisors be alerted as soon as a mother scores 13 or above on the depression scale.
Judge Cain also suggested that secondary carers, including fathers, were engaged by healthcare workers before the baby is born to look out for signs of depression or other mental illness.
He also recommended that other healthcare workers, including lactation consultants, were given education around mental health risks of postpartum women.
In 2022, Arbuckle pleaded guilty to infanticide, a rare charge that applies only to mothers who kill children under the age of two while suffering a "disturbed" mind linked to birth. She was ordered to continue treatment and supervision for three years.
beyondblue 1300 22 4636
1800 RESPECT (1800 737 732)
Lifeline 13 11 14
