Last month, a Victorian coroner called for a statewide electronic medical record with integrated trauma alerts after an eight-week-old baby was killed by his father after red flags were missed at multiple hospital presentations.

Before his final presentation to hospital, the infant was presented to two different EDs and was also assessed through the state’s virtual ED for a hole under his tongue. Retrospective reviews of X-rays taken at two presentations revealed healing or acute rib fractures.

State Coroner Judge Liberty Sanger also found cognitive bias had played a role, as the infant’s family did not have the usual red flags for family violence, such as financial or mental health risk factors or a drug or alcohol history.

For GP obstetrician Dr Vivienne Tedeschi, such bias is the most concerning feature of this case: