A coroner has called for steps towards a statewide electronic medical record and integrated inflicted-trauma alerts after an eight-week-old baby was killed following repeated hospital presentations with missed warning signs.

The death of the baby, whose father has since been jailed for child homicide, was one of the “tragic examples of situations in which a statewide electronic medical record [EMR] would have been beneficial”, Victorian State Coroner Judge Liberty Sanger said.

She concluded that there had been multiple missed opportunities to recognise possible non-accidental injury and intervene, citing evidence that identified “cognitive bias” and barriers to information sharing as contributing problems.

The baby first presented to the ED at Royal Children’s Hospital Melbourne in July 2021 with a bleeding nose. Non-accidental injury was considered in triage, but his mother denied that an adult could have caused it, and it was diagnosed as mechanical chafing.