In the depths of Melbourne's harshest lockdown, Siya Patel's parents knew something was wrong with their newborn daughter.
Yet despite their best efforts to navigate the state's then-heavily restricted healthcare system, 10 days later their baby had died.
Chaitali and Yoginkumar Patel had only moved to Australia three years earlier and weren't yet eligible for Medicare.
Because of this, neither was their Melbourne-born daughter, who died on September 12, 2020 from a brain injury caused by dehydration due to insufficient oral intake.
The family instead had "international visitor" private health insurance, which didn't cover some of the standard and otherwise fully funded postnatal reviews under Medicare.
This meant there were out-of-pocket costs for Siya's parents to receive free equivalent care afforded to Medicare-eligible families.
Siya's care was also impacted by Victoria's COVID-19 lockdown, which had Melbourne in stage-four restrictions at the time.
This included an initial maternal children health nurse visit being conducted by telehealth, with no video, instead of in-person.
These factors meant Siya's parents were not supported as new parents, and her insufficient intake and subsequent weight loss went unnoticed.
Her death was entirely preventable, Victorian Coroner Katherine Lorenz has now found.
Mr and Mrs Patel took Siya, who was born on August 20, to the Royal Children's Hospital on September 2 after she became unwell, encephalopathic, and had an abnormal cry.
She was soon admitted to the hospital's neonatal intensive care unit with high sodium levels and dehydration, along with complications including seizures and acute renal failure.
An MRI scan on September 8 showed multifocal haemorrhage, meaning Siya's blood had become so thick from dehydration it was causing damage to her brain and other organs.
Three days later Siya was transferred home at her family's request, where she died in her mother's arms, at 23 days of age.
Ms Lorenz found a "key underlying issue" in the case was the family's Medicare ineligibility, which resulted in a routine postnatal outpatient review coming with an out-of-pocket expense.
"Babies are not automatically eligible for Medicare just by virtue of being born in Australia: they must have at least one parent who is eligible for Medicare to also be eligible," she wrote in findings released on Wednesday.
"I consider that this is a considerable failure in healthcare policy which creates unnecessary barriers to accessing essential health care services and has contributed to Siya's death."
Ms Lorenz called on federal Health Minister Mark Butler to overhaul the Health Insurance Act to allow all babies born in Australia to be eligible for Medicare.
"I convey my sincere condolences to Siya's family for their loss," she said.
Mr Butler's office has been contacted for a response.
