Inquest into the death of Gia Lim

Case Number: 2019/0038819 

Date of Findings: 17 March 2026

Magistrate: Deputy State Coroner, Magistrate Rebecca Hosking

Catchwords: CORONIAL LAW - Midwifery Support Program; early discharge of babies; consultation as between doctors and midwives on neonatal wards; hyperglycaemia; intrauterine growth restriction; head sparing growth patterns; small for gestational age. 

Responses

Recommendations

To the South Western Sydney Local Health District (SWSLHD):

1. I recommend that a sample of standard maternity observation charts or maternity observation charts relating to culturally and linguistically diverse patients be audited to determine whether observations are being documented and recorded correctly, including at the required frequency, depending upon the clinical acuity of the patient.

To the General Secretary, Nursing and Midwifery Board of Australia:

1. That consideration be given to the Nursing and Midwifery Board of Australia reviewing and/or investigating RM Khan’s care of Gia during her maternity admission. I direct that a copy of the brief of evidence be provided to the Nursing and Midwifery Board of Australia.