Melissa Arbuckle: Judge finds cries for help from mentally-ill mother were ignored before she killed

A coroner has called for major reform to Victoria's maternal health services after finding mistakes were made in the lead-up to a nine-week-old baby's killing at the hands of her mentally-ill mother. 

Melissa Arbuckle, 32, was in the depths of severe postpartum depression and psychosis when she laid her daughter Lily on railway tracks near Upwey Station in Melbourne's east in July 2021.

The former vet had been taking her daughter for a walk in a pram when she began searching for train speeds and timetables near her home, the court was told.

Melissa Arbuckle (pictured), 32, was in the depths of severe postpartum depression and psychosis when she laid her nine-week-old daughter Lily on railway tracks near Upwey Station in Melbourne's east in July 2021

The mother laid the baby on the tracks in front of a moving train (stock image)

She messaged her husband saying the girl was unsettled before placing Lily on train tracks and lying down alongside her.

They were both struck by a train.

Baby Lily died after being airlifted to hospital, while Arbuckle survived with fractures and internal bleeding. She took her own life last January, after pleading guilty to infanticide.  

An investigation into Lily's death by State Coroner John Cain found key medical staff failed to adequately respond to Arbuckle's repeated cries for help.

Judge Cain said numerous steps were not actioned by the Maternal Child Health (MCH) nurses engaged with Arbuckle after she scored highly on a depression screening tool for new mums.

She scored 14 on the Edinburgh Postnatal Depression Scale (EPDS), indicating she was suffering serious depression.

An investigation into Lily's death by State Coroner John Cain found key medical staff failed to adequately respond to Arbuckle's repeated cries for help

Arbuckle's husband disowned her for killing his child (pictured: the couple in happier times)

Her score should have meant she was referred to her GP for a mental health review and an enhanced MCH program.

'(But) Melissa was not queried in relation to the risk she posed to Lily and was not engaged with Enhanced MCH services or additional supports,' Judge Cain said. 

'I am particularly concerned given that this was the second time that Melissa had made reference to experiencing difficulties with her mental health and wellbeing and had made comments, at an unknown date, to suggest that further inquiry regarding her risk to Lily was warranted.'

The coroner's court heard MCH nurses made five failed attempts to contact Arbuckle in the week before Lily's death, but did not request a police welfare check because she wasn't part of the enhanced program.

If she had been part of the enhanced program, the unanswered calls would have triggered an escalated response, according to the Yarra Ranges Council MCH nurse co-ordinator.

The coroner handed down a suite of recommendations to reform MCH care, including a focus on infant safety and that supervisors be alerted as soon as a mother scores 13 or above on the depression scale.

Judge Cain also suggested that secondary carers, including fathers, were engaged by healthcare workers before the baby is born to look out for signs of depression or other mental illness.

Arbuckle (pictured) worked at a veterinary clinic in inner eastern Melbourne for several years 

He also recommended that other healthcare workers, including lactation consultants, were given education around mental health risks of postpartum women.

In 2022, Arbuckle pleaded guilty to infanticide, a rare charge that applies only to mothers who kill children under the age of two while suffering a 'disturbed' mind linked to birth. 

She was ordered to continue treatment and supervision for three years.

In April last year, Arbuckle was allowed to walk free on a good behaviour bond. 

Just six years ago Arbuckle wrote about her then-successful and happy life as a well-respected veterinarian who travelled the world with her 'cheeky' husband.

READ MORE: How a successful young mum went from clucky top vet to laying her infant daughter on train tracks to die - before she was diagnosed with postpartum depression just ONE DAY too late

But after Lily's birth she developed severe major postpartum depression and psychosis.

She was diagnosed too late to save the life of her baby. 

The court heard in the weeks before Lily's death, Arbuckle had been 'really down' and believed she hurt the little girl after rocking her bassinet too vigorously, according to the summary read in court. 

She started to believe the child had suffered shaken baby syndrome as a result.

'She had a fixed delusional belief she had harmed her child and they were both broken,' Arbuckle's lawyer Megan Tittensor told the Supreme Court of Victoria in April 2022.

'She had a perfectionist personality and need for control … she wanted to be the perfect mother.

'She had come to believe dying was her only option. She would hear voices telling her she was a bad mother.' 

Crown prosecutor Robyn Harper told the court that on the day of the horror Arbuckle's sister and mother came to visit Lily. 

Moments after the visit, Arbuckle texted her husband and said their daughter was 'losing it after a feed' and decided to take her for a walk, Ms Harper told the court. 

A train driver then spotted Arbuckle walking on the tracks. 

The train driver told police he 'closed his eyes' when he knew a collision was imminent.

Arbuckle ended her life in January last year

The baby was struck and thrown under the carriage while Arbuckle was left with serious injuries.

The train came to a stop 41 metres further down the track.

Witnesses rushed to help the pair and helped to pull out the still breathing baby.

When first responders arrived at 5.18pm, Arbuckle was found still attempting to inflict injuries upon herself with railway ballast, bashing herself violently on the head with it.  

KNOWING THE SIGNS OF POSTPARTUM DEPRESSION 

There are many signs that someone may be struggling with postnatal depression. Some of the more common ones include: 

- having a very low mood

- feeling inadequate and a failure as a mother 

- having a sense of hopelessness about the future 

- feeling exhausted, empty, sad and teary 

- feeling guilty, ashamed or worthless

- feeling anxious or panicky having trouble sleeping

- sleep for too long or have nightmares worrying excessively about their baby 

- feeling scared of being alone or going out

In some cases, women may experience thoughts about leaving their family or worried that their partner may leave them. They could also have ideas about self-harm or doing harm to their partner or baby. In situations like this, you should seek professional help straight away.

Source: HealthDirect 

Her baby was rushed to hospital, but died shortly after from head injuries. 

The Supreme Court of Victoria heard Arbuckle's husband had since disowned her for killing his child.

Associate Professor Alexander Holmes later told the court Arbuckle had been planning on seeing her GP and getting a mental health care plan, but could not see it making any difference. 

Arbuckle had been experiencing auditory hallucinations that she was not good enough and that she had to take her own life. 

'The voices were there all the time and they were commanding, saying that you just had to do it,' Justice Dixon said. 

'You had thoughts that Lily was broken and that Lily could see that you were broken, "She could see that mum was broken and that we will both be better off dead. We wouldn’t suffer, we would both be dead". You said it was all you thought about. '

The court heard Lily's father, who has asked not to be named, has been profoundly affected by her death.

'He states that he loved Lily more than life itself and thinks of her constantly. He struggles with his feelings towards you,' Justice Dixon told Arbuckle.

'Some days he finds himself unable to go to work or to carry on. He says that the worst thing that could possibly happen to him has already happened and that seeing Lily at the hospital broke his heart.'

Justice Dixon noted she was 'acutely aware' that it was beyond the power of the court to repair the suffering and loss flowing from Arbuckle's actions.

'I accept your counsel’s submission that you are deeply remorseful for the suffering caused to Lily’s father and to all who loved her,' she said. 

'You also regret the impact on the driver of the train that struck Lily, and you. Your life and the lives of others has been forever changed.'

'I also accept that you feel that, because of your own actions, you are under a life sentence. At times you have believed that you deserve any suffering you have experienced since the commission of the offence, as punishment for your actions.'

Arbuckle ended her life in January last year.

For confidential 24-hour support in Australia call Lifeline on 13 11 14 or beyondblue 1300 22 4636.

For post-partum depression support call PANDA on 1300 726 306.

1800 RESPECT (1800 737 732)

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