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The Coronors Court of Victoria has released its findings into the death of a nine-week old infant who died by infanticide in 2021, without inquest.
Lily Grace Arbuckle, who lived with parents Melissa and Jed Arbuckle in Upwey, was struck by a train on the tracks between Belgrave Railway Station and Tecoma Railway Station on 11 July 2021, after her mum placed her on one of the train tracks in the path of the train before she was thrown underneath.
State Coroner, Judge John Cain, found in his finding delivered on 23 November 2023 that Melissa had no reported history of alcohol or illicit substance abuse.
“There is no family history of mental illness,” Judge Cain wrote in his findings.
“Prior to the birth of her daughter Lily, Melissa had no reported or known history of mental illness, suicidality or self-harm.”
Judge Cain said Melissa and her partner Jed met in 2015 when they were both students at Melbourne University, before getting married in 2019 and purchasing a house together in Upwey.
Melissa qualified as a veterinarian and spent a few years in clinical practice before working in pet health sales with Blackmores, according to documents.
“During the course of the Covid-19 pandemic, the couple decided to try for a baby and Melissa became pregnant in July 2020,” the judge said.
Melissa’s pregnancy is said to have been uncomplicated despite Lily’s birth being by emergency due to a “prolonged labour period”.
Lily was born on 4 April 2021, after which Melissa experienced a “number of issues” breastfeeding her daughter, as well as experiencing postnatal depression between the time of Lily’s birth and July 2021.
In May, Melissa advised she had attended her General Practitioner and scored 11 on the Edinburgh Postnatal Depression Scale (EPDS) and planned to be reviewed by her GP in two weeks time.
The coroner said Melissa raised lactation concerns with a lactation consultant, Dr Joanna Strybosch, throughout June that year.
Dr Strybosh advised later in court that her ‘formal education in perinatal mental health was scant at best,’ and she did not ‘recall learning about [postnatal psychosis] in any detail at all in either my training as an osteopath or as a lactation consultant’.
Both Lily and Melissa had also been provided with maternal child health services by the Yarra Ranges Maternal and Child Health Services (MCH); starting on 13 April 2021 when Lily was nine days old.
Postnatal depression was discussed during this home visit, with Jed and Melissa both deemed ‘well’.
Melissa and Lily then attended at MCH Centre for an appointment on 27 April 2021 for a four week consult; during which a mental health and wellbeing screen was conducted and Melissa noted that she was not feeling ‘down, depressed or hopeless,’ the coroner found.
Severe storms in June 2021 meant Melissa relocated to her aunt-in-law’s residence in Melbourne due to power being cut in the Upwey area; causing her “more stress” due to Lily becoming more unsettled.
After reporting at later consultations that she had ‘really struggled’ during these times, Melissa also mentioned that she was ‘still teary’ and felt overwhelmed and distressed during Lily’s birth due to her urgent caesarean section.
“On 5 July 2021, Melissa became alarmed about a rash on Lily’s leg and about her perception of Lily having lost condition in her leg and having a weaker cry.
“The couple took Lily to Angliss Hospital to be examined and were discharged with medical staff noting no remarkable findings.”
But Melissa did not accept this advice, according to the coroner, and became “increasingly convinced” something was wrong with her daughter.
On 7 July 2021, Jed asked a neighbour to check on Melissa because of his concern about her mental state.
On that same day, Melissa made a list of all the signs that she perceived in Lily, and became preoccupied with concerns that she had somehow injured her daughter.
“Melissa told her husband the day before her daughter’s death on 10 July 2021, that she had not been sleeping due to her concerns about what she might have done to Lily and that she was having suicidal thoughts,” the report read.
It was also revealed Melissa drafted and completed a suicide note and had “numerous social media conversations” with friends expressing anxiety about “medical issues relating to herself and Lily, lactation issues, feeling stressed without electricity at home and feeling inadequately support and worried about Lily’s wellbeing”.
On 11 July 2021, Melissa took Lily for a walk at around 10.30am, with family members visiting the house throughout the course of the day.
Later in the afternoon, family visitors had left by 4pm and Jed had left to play tennis.
Melissa left the house pushing Lily in her pram, sending a message to Jed at 4.18pm that read: ‘Muffin was losing it after a feed,’ and said she was intending to go for a walk with Lily as her mother and sister had left.
On her walk, Melissa searched for information about train timetables.
She then took Lily from the pram, holding her at chest height and using her hand to wave at an approaching train; seen by a train driver standing at the top of the Kumbada Avenue.
“At 5.06pm, Melissa was seen by a train driver holding Lily about six to ten metres from the track,” documents say.
“The train driver activated his train whistle as a warning when he realised that her manner was suspicious when she was about five metres from the track.
“He then activated the train’s full emergency braking system.”
After placing Lily on one of the train tracks in the path of the train, Melissa attempted to lay down on her side on the train track and they were then both struck by the train.
Melissa was seriously injured and suffered multiple fractures to her shoulder, neck and other injuries to the right side of her body.
Emergency services were contacted and Ambulance paramedics transported Melissa to the Royal Melbourne Hospital and Lily to the Royal Children’s Hospital.
Attempts to resuscitate Lily were unsuccessful and she was pronounced deceased later that night.
After Lily’s death, one of the MCH nurse’s engaged with Melissa, and according to documents noted during the conversation that Melissa had asked why there was not ‘a question there asking me if I want to hurt my baby?’ in reference to the EPDS.
Reportedly, the nurse agreed that this should be asked but ‘did not ask Melissa whether it was something she wanted to talk about’.
Forensic Pathologist Dr Linda Iles from the Victorian Institute of Forensic Medicine, who conducted the autopsy, decided Lily’s medical cause of death was from a head injury, which was accepted by the coroner.
Lily’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008; which includes deaths that are unexpected, unnatural or violent or result from accident or injury.
The relationship between Melissa and her daughter Lily was one that fell within the definition of ‘family member’ under the Family Violence Protection Act 2008, with Melissa’s actions in placing Lily on dangerous train tracks constituting family violence.
In April 2022, Melissa was convicted of infanticide; a criminal offence that is committed by a mother who was found to have murdered her child due to having not recovered from giving birth, or due to a disorder she had developed as a result of the child birth, in the Supreme Court of Victoria.
In his statement to the Court, Jed made repeat references to indicators that Melissa may have been experiencing post-natal anxiety or depression following their daughter’s birth, including; Melissa was ‘very anxious to be the prefect mum’, ‘she was always anxious about whether she was on the right thing. I don’t think she was ever satisfied that she was doing it right and she was always trying to improve things’ and ‘she didn’t give herself a break and she didn’t have anything to fall onto to take her mind off it. She was a bit obsessive about it and stated to see things that weren’t there’.
“‘About two weeks ago, Melissa was really down. She was really worried she had been shaking the bassinet too vigorously…over the weekend Melissa was really worried about her,” Jed said in his statement.
Melissa reportedly advised Jed that she would not carry through with plans of suicide because of the consequences for him.
“‘I took it a bit naively because I didn’t think she would actually do anything, I was applying logic to it but it wasn’t logical,’” Jed said in his statement.
According to the coroner, Jed’s statement suggests that he was “unclear of the seriousness of the situation” and the impact that these experiences were having on Melissa’s wellbeing.
A message to a neighbour who had been supporting Melissa, from Jed, read: ‘I don’t really know the best way forward at this point, but I think it involves getting professional help for Melissa as you suggested the other day’.
Melissa was released on an adjourned undertaking of good behaviour for three years and continual mental health treatment.
On 9 January 2023, 33-year-old Melissa was found dead at a truck stop on Princes Highway in Flynn after taking a mix of drugs including propranolol, oxycodone, diazepam, temazepam, lurasidone and duloxetine.
She had purchased a home in Traralgon in November 2022 where she planned to move in in mid-2023 with her partner Hayden Brook, after the pair struck up a new relationship together in April 2022.
In his recommendations in the coroners report, Judge Cain suggested the International Board of Lactation Consultant Examiners review their requirements for lactation consultant accreditation and ensure that they must have undertaken education that includes a demonstrated understanding of postnatal mental health, how to identify mental health risks and making referrals for appropriate supports to qualify for accreditation.
He also recommended the Victorian Department of Health – Maternal and Child Health Services, introduce a process to ensure supervisors are “automatically alerted” if a primary caregiver scores 13 or above on an Edinburgh Postnatal Depression Scale (EPDS) so supervisors can ensure that a plan is in place for managing the risk posed to the primary caregiver and their child.
“With the aim of improving the public health and safety, I recommend that the Victorian Department of Health – Maternal and Child Health Services provide staff with regular training to ensure that they are familiar with the need to query infant safety following completion of question 10 of the EPDS,” he said.
“This education should be supported by ensuring that discussions of client responses to this question forms a part of regular clinical supervision.
It was also recommended the department of health require health services to engage with secondary carers on at least one occasion in the pre-natal period for the purposes of providing education around signs and symptoms of post-natal depression, anxiety and psychosis and options for support, noting that this engagement should only occur after permission is sought from the primary carer to do so.
“With the aim of improving the public health and safety, I recommend that the Victorian Department of Health – Maternal and Child Health Services introduce an additional consultation into the key ages and stages framework that requires MCH Nurses to proactively engage with the secondary carer for the purposes of providing education around signs and symptoms of post-natal depression, anxiety and psychosis and options for support, noting that this engagement should only occur after permission is sought from the primary carer to do so.”
Judge Cain conveyed his condolences to Lily’s family for their loss.
If you or anyone you know needs support call Kids Helpline 1800 55 1800, Lifeline 131 114, or Beyond Blue 1300 224 636.
