Infant death findings
Coroner identifies ‘significant deficiencies’ in care
A CORONER has said if the Child Safety Service had taken lost opportunities to protect six infants and one child they might not have died, but the service did not cause their deaths.
Coroner Olivia McTaggart handed down her findings into the deaths of six infants and one child between 2014-18 on Wednesday.
The deaths included a 16year-old girl and her baby, who both died following a car crash because the infant’s father and girl’s boyfriend had driven unlawfully.
The six infants were below seven months old. Four died suddenly and unexpectedly during apparent sleep and three were in an unsafe sleeping environment. One died from natural causes and another drowned in the bath.
Ms McTaggart said in the case of one infant, “it appeared from the investigation that CSS was unaware of his birth”.
She said each child or their family had been involved with the child protection system.
“Despite significant CSS deficiencies in responding to notifications, I am not able to determine to the requisite standard that the deficiencies played a causal role in the child’s death,” she said.
In the case of the mother and baby boy, Ms McTaggart said there were “many opportunities for CSS to have properly assessed risk and to have taken timely action to protect the mother and infant”.
But the coroner noted children should only be removed from families as a last option.
Ms McTaggart said the ultimate responsibility for each child resided with parents, and noted health professionals had discussed correct sleeping practices with parents.
She said CSS had “lost opportunities to protect the vulnerable infants which, if they had been taken, may have resulted in a different outcome”.
Child protection expert witness Professor Bob Lonne noted risk factors in the deaths were vulnerability, economic and social disadvantage, the young age of some parents, and the families’ involvement in domestic violence and drugs.
The professor found the CSS had “poor internal communications” and a “propensity to prematurely close cases under the assumptions that other agencies were continuing to work closely and effectively with the family”.
Professor Lonne made 11 recommendations, including creating a new policy and procedure to quickly identify new high-risk cases and finalising the monitoring and evaluation framework for the Strong Families, Safe Kids (SFSK) reforms.
The Community and Public Sector Union said the CSS suffered “chronic understaffing”, retention and recruitment issues.
Ms McTaggart urged the Tasmanian government to “fully support the completion of the reforms” in relation to the SFSK.
“It is this reform that may address the multiplicity of issues seen in this inquest and result in the decrease in risk to vulnerable infants and children,” she said.