Inquest into the death of KP

Case Number: 2022/00017352

Date of Findings: 30 May 2025

Magistrate: Deputy State Coroner, Kasey Pearce

Catchwords: CORONIAL LAW – death of 3-month-old baby – family known to Department of Communities and Justice – cause and manner of death 

Responses

Recommendations

To the Chief Executive Officer, Albury Wodonga Health (AWH), Murrumbidgee Local Health District (MLHD)

1. That AWH and MLHD consult with a view to formalising the administration and governance of the SAFE START Program for the Murrumbidgee Local Health District and the Albury Wodonga Health catchment, which is networked with Victoria. This consultation should consider formalising: 
   • a clear and documented allocation of roles and shared distribution of responsibility for the administration of the SAFE START program between each health Service; 
   • which agencies will be responsible for the administration of the program; 
   • expectations for participation by the agencies in case management meetings;
   • minute taking and distribution of minutes; and
   • a process to identify and track agreed action.