A 45-day-old baby died as a result of two episodes of severe trauma to his head inflicted by his father, a Tasmanian coroner has found.

Baby Bjay Adam Johnstone died at the Royal Hobart Hospital (RHH) in November 2012 after being admitted with severe head injuries, broken ribs and haemorrhaging from the eyes.

Coroner Olivia McTaggart said the baby might still be alive had Child Protection Services (CPS) not failed in its duty of care.

It was found the abuse had started before the newborn had even left hospital.

The coroner said Bjay's head injuries took place in a setting of extended physical abuse between his birth on October 14, 2012, and his death.

Simon Johnstone was jailed in 2013 for 18 months for assaulting his baby son. ( ABC News: Laura Beavis )

His father, Simon Adam Johnstone, was previously jailed for two-and-a-half years for ill treating the baby, but police were unable to determine who inflicted the fatal injuries.

Ms McTaggart found Bjay's mother Fleur Atkin did not protect him as she had a duty to do and she could have prevented his death.

The coroner said the "violence and control to which [Ms Atkin] was subject by Simon Adam Johnstone contributed to her failure to act".

She said bruising was noticed on the baby by Ms Atkin, before Bjay left hospital.

In her findings, Ms McTaggart described an incident the day before the baby's release.

"On this same date, Ms Atkin went to the toilet in her hospital room, leaving Mr Johnstone and Bjay in the room alone," she wrote. "When she came out of the bathroom she observed Mr Johnstone holding Bjay tightly around the throat and then throwing him down onto the bed."

Mr Johnston was later charged and convicted of this assault but Ms McTaggart said at the time, no-one in authority was made aware of the incident and it had not been reported by Ms Atkin.

Ms McTaggart said Bjay's paternal grandmother and uncle also did not protect him as they had a duty to do, nor did Child Protection Services (CPS).

Multiple failures by child protection

Ms McTaggart said there were "extensive failings" by CPS in Bjay's case with three notifications made by nurses to CPS, including one before the child was even born, being ignored.

"Those failings reflect, in my view, entrenched systemic and cultural deficiencies in the context of inadequate resourcing," she said.

"The evidence very strongly indicates that the pressure upon the individuals and the organisation, the inexperience and turnover of the workers, inadequate staff numbers and lack of training were constant issues preventing effective responses to the notifications."

Among CPS recommendations Develop child protection liaison positions in north, north-west

Develop child protection liaison positions in north, north-west Establish system to ensure notifications acted on

Establish system to ensure notifications acted on Paediatrician be involved if bruising involves infants under six months

Paediatrician be involved if bruising involves infants under six months Increased powers for department secretary to intervene for children at risk

Increased powers for department secretary to intervene for children at risk Protocols to identify family violence perpetrators

In a statement, secretary of the Department of Health and Human Services, Michael Pervan said child safety was "one of my department's most critical roles" and it would "carefully examine the coroner's findings and recommendations".

"I understand that this case has had a severe impact on a large section of the Tasmanian community. It is traumatic, and for many, difficult to comprehend," he said.

"I extend my sincerest sympathies to the people who have been affected by Bjay's death.

"It indeed was a genuine tragedy - and one we all must strive to ensure is not repeated.

"We always strive to do things better. We always need to learn from situations where things go wrong."

Mr Pervan said "we need to learn from a tragic outcome, and therefore, I welcome the coroner's report".

Despite the coroner's finding it is unlikely any fresh charges will be laid over Bjay's death.

Police failed to take 'timely steps'

Mr McTaggart found Tasmania Police did not take steps towards attempting to ensure the baby's safety at a time before he may have suffered a fatal injury.

The coroner said Mr Johnstone's violence towards Fleur Atkin contributed to her failure to act. ( ABC News: Laura Beavis )

During the inquest, it was revealed Bjay died less than a month after a call to Tasmania Police on October 29 by an English woman who was concerned about his welfare.

"At the outset, I am not able to find that Bjay would have survived if police action had been taken without delay to investigate the report and/or refer the allegation of abuse to CPS," Ms McTaggart said in her report.

"However, I have determined that Bjay suffered a severe head injury between 28 and 31 October which either contributed to, or was the major cause of, his death.

"Police action in relation to Bjay did not occur until police became involved again upon his hospitalisation on 2 November. An opportunity arose for police to take steps towards the protection of Bjay from 29 October to 2 November.

"As the report was not investigated, the opportunity was lost."

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