Dead infant Noah Harrison had bone fractures, Adelaide inquest told

A coroner has recommended a lower reporting threshold for suspected child abuse after the death of a South Australian infant who was later noticed to have had bone fractures.

Deputy coroner Anthony Schapel found child health workers could have got more involved ahead of the death of Noah Alexander Edward Harrison, who was almost three months old, in October 2010.

A court heard the infant had four bone fractures that were not picked up during an X-ray, but Mr Schapel said the doctor at that time had been treating another matter, so failing to recognise the injuries was understandable.

"The only information Dr [Claudio] Coscia was given in respect of Noah's clinical presentation was that he was a febrile infant," the coroner said.

"Dr Coscia had no particular reason to examine the radiological imagery of Noah's skeleton as revealed by the chest X-ray and in particular had no specific reason to examine a limb or limbs.

"I have found that in all of the circumstances it cannot be said that Dr Coscia's failure to recognise the bone injuries was unreasonable."

On the infant's specific cause of death, Mr Schapel said the boy had been sleeping in a pram and it was hard to escape the conclusion that he might have suffocated.

"If one were to view the matter completely dispassionately it is difficult to escape the conclusion that, out of all the possible competing causes of death, suffocation or asphyxiation due the child's sleeping position is the most likely," he said.

"That is not to say however that it is a cause of death that has been established as being more likely than not. In all of the circumstances the court is unable to arrive at a cause of death."

Coroner said boy's low weight noteworthy

Mr Schapel recommended those doing X-rays be given a "complete clinical picture" and that imagery be routinely examined for bone injury.

The boy had been seen several times by home-visit nurses from the Child and Family Health Service (CaFHS).

Mr Schapel said staff perhaps should have increased their scrutiny because the boy was underweight.

"There could have been greater concern entertained in relation to Noah's circumstances, having regard to his history of inadequate nutrition, his presentation at [hospital] and in light of his mother's statements that she was not sure whether she wanted Noah," he said.

"Noah's circumstances warranted particularly close scrutiny from CaFHS."

He recommended in future home-visit nurses thoroughly investigate a child's sleeping environment and take photographs when possible.

"CaFHS nurses and other workers should give appropriate consideration as to whether or not a parent or parents of an infant might require assessment or care in relation to the mental health of that parent or parents, and to recommend the appropriate services," he said.

Suspected abuse threshold 'should be low'

He recommended a low threshold for reporting cases of suspected abuse to government agency Families SA.

"Had a notification been made to CARL (Child Abuse Report Line) in respect of Noah, it is likely that Families SA would have been under a duty to rate the notification as a tier one, requiring an urgent response within 24 hours," he said.

"This would probably have resulted in an approach by Families SA to the family and admission to WCH (Women's and Children's Hospital) for a forensic medical assessment.

"If the final forensic medical opinion was such that Noah's fractures were likely to have been inflicted, and that there was no underlying predisposition to bone fracturing from lesser force, Families SA would have been under a duty to ensure Noah's safety on discharge.

"To my mind such a duty would have encompassed a proper assessment of Noah's sleeping environment."

The coronial recommendations were directed to the South Australian Health Minister and to the director of the Child and Family Health Service.