Baby Malakai's Coronial Finding: What It Does — and Does Not — Prove

7 min · Medical negligence

When a coroner identifies problems in medical care, it is natural for a family to ask whether those findings prove negligence. The short answer is no. A coronial finding can establish important facts and expose failures in care, but it does not decide a civil medical negligence claim.

The Victorian Coroner's finding into the death of Malakai Cross-De Jesus, signed on 8 January 2026 and published by the Court on 27 January 2026, shows why that distinction matters. It also shows how much can turn on the clinical timeline, the records and expert evidence.

Baby Malakai was three days old when he died. His parents' loss sits behind every part of the finding. It should be read with that in mind.

What the coroner found

Malakai was born at the Joan Kirner Women's and Children's Hospital on 20 July 2023 following a forceps delivery. He later deteriorated and was transferred to the Royal Children's Hospital, where he died on 23 July 2023. Coroner Ingrid Giles accepted the medical cause of death as complications following forceps delivery.

The coroner accepted advice from the Coroners Prevention Unit that two factors contributed to the death:

the decision to proceed with an instrumental delivery in the birth suite, rather than in an operating theatre under the supervision of a consultant; and
delayed recognition and management of a subgaleal haemorrhage — bleeding into the space between the scalp and skull.

An independent obstetric expert identified a series of warning signs that, in his opinion, should have prompted reassessment in an operating theatre with a consultant obstetrician. That setting would have allowed another assessment of whether to continue with forceps or use another delivery method.

The finding was also careful about what the evidence could not establish. The expert could not determine from the medical records whether excessive traction had been applied during the forceps delivery. Staff interviews obtained during the health service's review did not identify evidence of excessive force, and the number of pulls was not considered excessive.

That is an important distinction. The accepted medical cause of death was complications following forceps delivery, but a serious outcome does not, by itself, establish that the force used was negligent.

The delay in recognising the bleed

The finding records that Malakai was at high risk of subgaleal haemorrhage. Relevant factors included the instrumental delivery, a low Apgar score at five minutes, prolonged labour and multiple pulls.

The bleed was recognised only after Malakai had become critically unwell. Western Health's own root cause analysis found that a CPAP bonnet used to support his breathing obscured observation of his scalp. It also identified a loss of situational awareness during resuscitation and a focus on sepsis as an explanation for his deterioration. Those factors delayed recognition and management of the haemorrhage.

The coroner could not determine with certainty that earlier recognition, or a transfer to theatre, would have prevented Malakai's death. She found, however, that either step would have optimised his chances of survival.

That careful language is central to the finding. It identifies missed opportunities without claiming certainty that the evidence could not support. It does not, by itself, establish the separate causation test in a civil claim.

What changed after Malakai's death

Western Health accepted the Coroners Prevention Unit's two main contributing factors. By the time the finding was signed, it had reported several changes, including:

targeted neonatal intensive care education on assessing, recognising and managing subgaleal haemorrhage;
weekly simulation training involving senior neonatal medical staff and a new tool for responding to deteriorating babies;
a requirement that complex forceps deliveries involving a high head and manual rotation take place in an operating theatre; and
review and simulation testing of its critical bleeding and massive transfusion procedures.

The coroner also recommended that the Royal Children's Hospital formulate or update a statewide clinical practice guideline for neonatal and paediatric patients who trigger a massive transfusion response, including guidance on sourcing a particular clotting medicine.

The finding referred to Victorian guidance on subgaleal haemorrhage published by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity in April 2025. That guidance expects Victorian health services to have protocols for identifying the risk factors, recognising the signs, observing the newborn and treating the bleed.

Why this is not a finding of medical negligence

The coroner explained the boundary at the start of the decision: a coronial investigation establishes facts surrounding a reportable death. Its purpose is not to cast blame or determine criminal or civil liability. That role is set by the Coroners Act 2008 (Vic).

A medical negligence claim asks separate questions. A lawyer must assess whether the care fell below the legally required standard, whether that failure caused the injury or loss claimed, and what evidence can prove each step. Those questions are governed by the civil law, including the Wrongs Act 1958 (Vic), not by the coronial finding alone.

That means a coroner's criticism does not automatically prove negligence. Equally, uncertainty in a coronial finding does not decide the civil question. The evidence has to be assessed for the particular claim and under the applicable legal tests.

You can read more about those tests in How to establish a medical negligence claim.

What a coronial finding can provide

Although it does not decide liability, a coronial finding can give a family a substantial factual foundation. In this case, the published finding brings together:

a detailed treatment timeline;
the medical records;
post-mortem findings;
an internal root cause analysis;
advice from the Coroners Prevention Unit;
an independent obstetric opinion; and
the health service's response and changes made after the event.

It also exposes gaps. Here, the records documented the timing of each forceps pull but did not contain enough detail for the expert to determine from the records alone whether excessive traction had been used. The staff interviews became relevant to that question.

This is why a medical negligence assessment is more than reading one report. Records, policies, witness accounts and independent expert opinion have to be tested against one another. The chronology often reveals where the real questions sit.

If you are trying to understand a birth injury

You do not need a coronial finding before asking a lawyer to review what happened. Many serious injuries never go through a coronial investigation. The practical starting point is usually to secure the complete records, build the timeline and obtain advice from an independent expert in the right specialty.

The honest answer may be that the evidence does not support a claim. It may also show that a concern deserves a closer look. Either way, the task is to separate what is known, what is missing and what still needs expert evidence.

Medical negligence claims are also subject to strict time limits. See Time limits for medical negligence claims in Victoria rather than assuming a coronial process has stopped or extended the clock.

If you want us to review what happened, you can start a free assessment. There is no obligation and no guaranteed outcome.