Inquest into the death of Serena Lee

Case Number: 2021/310546 

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. That the SWSLHD conduct an audit to ensure that the equipment identified in the Midwifery Support Program (MSP) Policy as available to midwives on the MSP is available, working and properly calibrated, and that staff are trained in the use of it. 
2. That the SWSLHD immediately ensures that material relied on by MSP midwives and handed out or shown to new parents is up-to-date and consistent with current best practice.
3. That the SWSLHD consider further amendment to the MSP policy to provide guidance as to the circumstances in which a neonate’s blood glucose level should be monitored, inclusive of consideration of requiring or recommending monitoring where there have been two successive feeds missed. 
4. That the SWSLHD consider undertaking a review of the MSP Policy including seeking input from midwives currently working in the MSP with a view to amending the MSP Policy to exclude patients which, from the perspective of the midwives, are not considered to be low risk. 

To the President of the Medical Council of NSW:

1. I recommend that consideration be given to the Medical Council of NSW reviewing and/or investigating Dr Danesh Hewa-Gamage’s care of Serena, and his decision to discharge her. I direct that a copy of the brief of evidence and transcript of the coronial inquest be forwarded to the President of the Medical Council of NSW.