How series of blunders doomed ‘Baby A’ to a miserable death in Melbourne’s Dame Phyliss Frost Centre

A newborn baby that died in jail less than two weeks after being born to her drug addicted mother never stood a chance. 

In death, the fragile little girl can still only be referred to as ‘Baby A’ – her name suppressed by a justice system that now pontificates on the merit of protecting the safety of her parents. 

It is a pseudonym as cold as the compassion shown to the newborn by a justice system still confused about what it’s obligations to her life actually were. 

A bird’s eye view of Melbourne’s notorious Dame Phyllis Frost Centre. It houses some of Australia’s worst female prisoners

Babies are made to wait for treatment inside Dame Phyllis Frost Centre in Melbourne.

On Monday, Victorian Coroner John Olle began the important task required to not only answer that question, but work out how and why Baby A came to die in custody.

The inquest comes almost three years after an investigation by Daily Mail Australia exposed the needless tragedy. 

‘Baby A’ was just 12 days old when she died inside the dedicated ‘Mothers and Children Units’ at Victoria’s Dame Phyllis Frost Centre in 2018. 

The jail houses some of the nation’s deadliest women, including gangland matriarch Judy Moran and the ‘Black Widow’ serial killer Robyn Lindholm. 

Baby A had been born at the Sunshine Hospital on August 6.

Her mother, who cannot be named, was in custody on remand throughout the pregnancy and had been under the care of midwives. 

At the time, she was taking methadone to manage her addiction to heroin and methamphetamines – the deadly drug known as ice.

Baby A was born by C section after an attempt to induce her failed. 

She spent eight days in hospital, much of it in the special care nursery, where she was treated for jaundice and monitored for signs of methadone withdrawal. 

On August 14 mum and baby were allowed to live together at Dame Phyliss Frost despite concerns by medical staff that all was not well. 

The very next day Baby A was back at hospital after being assessed by the visiting midwife as having lost further weight and showing signs of jaundice. 

Baby A and her mother spent a further two nights together in hospital before again being discharged back to the prison despite the concerns of worried staff.

She would be dead by the next morning. 

Why clearly struggling mums and newborn babies are allowed to live together in jail is not something the coroner will be investigating. 

It is only the circumstances surrounding Baby A’s untimely death that is within his scope. 

Baby A’s cause of death has been determined as SIDS category 2, which is a term used by experts for otherwise unexplained deaths of children aged under three weeks of age.

Her mother had been in jail on drug charges and had a shocking history of drug abuse. 

Victorian health department child protection workers never wanted Baby A placed in Dame Phyliss Frost with her mother. 

Women live together in large groups inside the women’s prison

Dame Phyllis Frost Centre now contains a room that no other inmate dares sleep inside of. It is the room where a newborn baby died 

On May 20 the person responsible for the prison program emailed members of a steering committee, which included a Corrections Victoria representative, seeking their agreement to support the application.

‘For reasons which are unclear’ the email did not go to the child protection representative.

Other members of the committee supported the application, as did the general manager of the jail after a meeting she had with Baby A’s mother on May 25. 

On May 30 Baby A’s doom was sealed. 

While child protection workers eventually found out Baby A had been moved to jail, they failed to lift a finger to express concern. 

Counsel assisting the coroner Rachel Ellyard told the court it appeared there was ‘acquiescence in the decision’.

‘Certainly, it seems that later on, a belief that Child Protection knew of and approved the decision may have influenced the decision making of others,’ she said.


The coroner heard that the decision to discharge Baby A was made in the context of her mother’s distress at the thought that Baby A might remain in hospital without her, and where Baby A was still underweight and medically compromised.

The coroner was told those making or contributing to discharge decisions did not appear to consider Baby A was at any risk being discharged to her mother’s care in prison and that they may have been influenced by a belief that there would be supports for them in the prison and that Child Protection had no concerns.

‘It appears on the evidence that there was a clear view that having her child with her in custody would be of great benefit to Baby A’s mother … it is less clear what attention was given to the potential risks to Baby A or the particular needs she might have and whether they could be met in a prison setting.’

Alarm bells had been ringing among hospital staff upon Baby A’s birth. 

Her mother resisted advice from nurses and doctors about safe sleeping practices, preferring to hold her baby. 

Upon her first discharge, Baby A weighed 2550 grams, a 13.5 percent weight loss since birth and eight grams less than the last weight a day earlier. 

The weight loss was noted by nursing staff and drawn to the attention of the paediatric registrar, but the doctor who discharged her appeared unaware of the weight loss. 

Back in jail, Baby A was effectively at the mercy of her mother. 

The unit did not include supervision or support from a nurse or other trained professionals.

Prison officers were not trained to provide support or supervision, and for the most part women were entirely responsible for the care of their infant, Ms Ellyard said. 

Dame Phyllis Frost Centre can hold 604 inmates and contains a dedicated unit for mothers and their children, from babies up to to pre-schoolers

Within days Baby A was back in hospital. 

Again she was discharged despite the concerns of some hospital staff, who noted while she had gained a small amount of weight, was still well under her birth weight at 10 days of age. 

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Hours later Baby A was dead. 

On Thursday, an inmate referred to as ‘Alice’ told the inquest that prison nurse Georgina Melody refused to assist the newborn after an inmate had been forced to administer CPR. 

‘The nurse just said “Oh I’m sorry”. That was it … she did not touch the baby,’ Alice said. 

Alice had been the first inmate to hear Baby A’s mother scream for help about 5.30am. 

‘Baby’s not breathing,’ the desperate mum shouted. 

While other mother’s caged within the unit flew into a panic, Alice tried desperately to get prison guards to open the door and provide help. 

‘They kept hanging up on me,’ Alice said. ‘They said they’d called a code and said we’d just have to wait … we didn’t know what to do.’

Alice said when prison staff became frustrated with her repeated calls they cut the intercom to the room. 

The court heard the prison guards stood by and watched as another inmate, referred to as ‘Donna’, performed CPR on the baby. 

‘They said they needed permission to open up,’ Alice said. 

When prison staff finally entered the unit, Alice claimed they treated the hysterical mother with cold disregard. 

‘There was no comforting,’ she said. ‘Someone asked her where the baby had been sleeping.’

Coroner Olle heard mothers sharing the unit had been warned to always ensure their babies slept in their cot – never in bed with them.

It was a rule often ignored after the mothers were sealed within the unit at 7pm each night, Alice claimed. 

The inquest was told Baby A was spotted lying alone on her mother’s bed just hours before she would die, although her mother maintains she had been sleeping in her cot.  

Inside Dame Phyllis Frost: Inmates were forced into lockdown for four days after a baby died in the dedicated Mothers and Children Units in August last year 

The coroner heard while Ms Melody refused to provide CPR to the baby, firefighters who later attended the unit worked frantically to try and revive her. 

Beth, not her real name, told the inquest inmates pleaded with the guards to ‘open the f**king door’. 

‘Everyone was panicking,’ she said. 

The young mother further claimed their babies were all but abandoned by their jailers after dark. 

‘At night it is quite difficult for us especially when the baby gets sick or has a temperature,’ Beth said. 

‘We press the intercom, we wait for confirmation and then they need to do something, but at least it’s half an hour or one hour they will bring Panadol for the kids and then log book and everything needs to be done – it’s quite difficult – but this happens at night time.’

Donna told the inquest Baby A had appeared fine on the night she would die. 

The court heard Baby A’s mother had only returned from hospital that afternoon and went on a cleaning frenzy while holding her before going to bed. 

It was Donna who rushed to the baby’s aid to perform CPR upon hearing her mother’s cries for help. 

‘My maternal instincts kicked in,’ she said. ‘All of the other mums were just standing around.’

Donna told the court she feared Baby A might already have been dead.  

‘There was no life. She felt like a rubber doll … I could see the baby was gone. It was too late.’ 

Inside a standard prison cell within the Dame Phyllis Frost Centre. A coroner is expected to investigate how a baby died within its concrete walls

The inquest heard Baby A’s mum had earlier expressed a desire to return from hospital with her baby despite fears from hospital staff that she was dangerously underweight. 

Alice claimed Baby A’s mum had told her hospital staff had demanded her baby consume a full bottle of baby formula before they would allow her to go back to jail. 

When Baby A’s mother became agitated, she was handcuffed to a bed, Alice claimed. 

The court heard the prison nurse’s decision not to assist the baby shocked not only the baby’s mother, but prison staff and investigators. 

In a gut wrenching impact statement, the baby’s mother addressed her dismay at the alleged failure of her jailers to help. 

‘I still cannot understand why none of the staff did CPR or anything for the baby until the firefighters arrived,’ she told the court. 

Multiple prison guards expressed similar concern about the nurse’s alleged failure to provide assistance to the baby. 

‘I did not see the nurse perform any CPR on the child. I found this to be quite distressing to witness,’ one guard said. 

‘I was surprised and distressed by this lack of action,’ another said. 

A prison operation supervisor told the inquest he too was upset about Ms Melody’s ‘inaction’ on the night. 

‘I was taken aback by the fact that nobody was giving medical treatment to the baby,’ he said. 

The inquest continues.


The mother and underweight baby had only been discharged from hospital that afternoon.  

The inquest heard Baby A’s mum had been a long term drug addict, which saw the child born is custody with an addiction to methadone – a drug used to wean drug addicts off heroin. 

Despite concerns about granting Baby A’s mum access to the child in prison, child welfare staff had been left out of the loop when the decision was ultimately made by a steering committee, and did nothing when they eventually found out just days before the child died. 

The coroner will determine if the desires of Baby A’s mother to be with her baby clouded the minds of those that made decisions placing the baby back in custody with her. 

Baby A had been discharged from hospital just days after birth before returning for two additional nights due to weight concerns. 

On the afternoon Baby A was discharged again she had weighed less than her birth weight just days earlier. 

‘It may be that Baby A was already beyond help, but the evidence will consider whether overall Baby A and her mother received a timely response, remembering that they were locked in a prison unit with no access to the outside world other than through the assistance of prison officers,’ counsel assisting the coroner Rachel Ellyard  said.   


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