Baby Asher: Record coroner’s backlog leaves families waiting years for change that could save lives

Baby Asher’s death has left a heartbreaking hole in family photos, but his parents say an agonising three-year wait for answers has made their grief far worse. The West Australian can reveal a huge increase in families, such as the Walkers, waiting for more than a year for an official cause of death, as a backlog at the State Coroner’s office exceeds a thousand cases for the first time. Health authorities have apologised for the death of seven-day-old Asher Walker at King Edward Memorial Hospital, after they confirmed hospital guidelines were not followed during his delivery. He had a “catastrophic” loss of oxygen after an 11-minute delay in calling a code blue. Mother Immi Walker fears the coronial delays are leaving other lives at risk. “We just think of him, and we miss him and I wonder what he could have been like,” Ms Walker said. “Separate from how we were let down, separate from the chaos, he was beautiful and squishy and so loved. “I just wanted to know, very clearly, with confidence, that the cause of death would outline that the mismanagement did this. “As a mum, your brain tries to problem solve and I just wanted to understand. “There were so many little things that just weighed on my heart. . . he just didn’t deserve that.” New figures have revealed the official backlog of coronial reports, which have taken more than 12 months to release, increased by 30 per cent in 2024/25. The State Coroner’s annual report blamed the increase on external factors, including long waits for pathology reports. “The overall backlog has increased from 804 cases to 1049 cases,” acting state coroner Sarah Linton said. “This has predominantly occurred through delays to the provision of toxicology reports and post-mortem examination reports by the responsible agencies.” Out of the cases that were closed, 1434 cases took longer than 12 months and 171 cases took longer than two years. Yet, only two per cent of the 3360 coronial cases completed last financial year proceeded to an inquest. Shadow health minister Libby Mettam said years-long waits for coronial reports was unacceptable, cruel and negligent. “These unacceptable wait times compound the tragedy and stress and raise real concerns about the ability of our coronial system to deliver critical findings in a timely way,” she said. “For a family to be waiting three years for a cause of death is simply inexcusable. “In a State as wealthy as WA, it is both cruel and negligent that this government is overseeing totally inordinate delays in the preventing potential future tragedies.” A State Government spokesman said it was working with the court to ensure it was equipped “to deliver timely, compassionate outcomes for families, while maintaining the integrity and thoroughness of its investigation.” And a spokeswoman for the Coroners Court said there has been “ongoing communications” with the Government about resourcing. “More recently, circumstances within the court has led to a temporary appointment of an additional coroner for a short period,” the spokeswoman said. PathWest said it has introduced measures to meet increased demand for pathology reports, and had slashed its backlog by almost 50 per cent since July. Similarly, ChemCentre reported “substantial progress” in the past nine months and a 65 per cent reduction in cases awaiting completion. But the Walker family says the delay silenced them, and they want a further investigation into the birthing protocols for big babies, such as Asher, to prevent the shoulder dystocia that caused Ms Walker’s obstructed labour. Asher’s death was eventually officially listed as being due to “natural causes”. But a root cause analysis by the North Metropolitan Health Service, which operates KEMH, found that an 11-minute delay in calling for a “code blue” emergency response may have contributed to the baby’s death. “Calling of the emergency code as soon as the patient was moved to the bed may have led to a different outcome for the baby,” the NMHS report said. “There was no clear communication between staff that this was an emergency situation. “There was no clear lead managing the shoulder dystocia. (The) timing for each manoeuvre was not called out as recommended in clinical guidelines.” Finally, three years after baby Asher’s death, the coroner made no recommendations in his case, but noted that NMHS had promised to update clinical guidelines that were “out of date” when he was born. It was also recommended emergency training required every five years be made mandatory every 12 months. “We offer our sincerest apologies to Mrs Walker for her and her family’s distress and the tragic loss of baby Asher,” NMHS chief executive Robert Tom said. “The delivery of high-quality, safe care is our highest priority, and we remain committed to making ongoing improvements for the safety of our patients.” Ms Walker said the three-year wait for a cause of death delayed her successful legal action against NMHS and added to her anxiety during the birth of his brother Miller, a year after Asher’s death. “It did deprive us of a bit of joy. Until we were holding Miller, I just loved him the same way I loved his brother and wanted to keep him safe, and I didn’t believe that I could,” she said. The family also recently welcomed baby sister Elodie. “(The wait) stopped us highlighting things that could protect other families,” Ms Walker said. “It ended up having a physical toll too, because it affected our mental health for so long, just not knowing, not having the official cause of death. “We felt like were a bit silenced because we couldn’t know for certain. “Even though we were wronged, we didn’t want to get anything wrong and upset anyone.” There was no inquest into Asher’s death and the family has been told many cases of shoulder dystocia, among children who were stillborn, were not investigated. “It blows my mind that it doesn’t fall under a preventable cause of death,” Ms Walker said. “It is jarring to know that, as a parent, sometimes you’re not enough to protect your children and then all the governing bodies that should be able to give you answers and protect them, everywhere we look there’s too much grey area.”