Inquest into the death of Bradyn Stuart Dillon

Contributing factors

• failure of CYPS to escalate concerns despite multiple bruising reports
• closure of case files without verifying information or obtaining Section 862 records (mental health, drug, criminal history)
• failure to recognise cumulative harm across 12 reports
• inadequate police liaison—rejection of referrals without proper assessment of risk indicators
• over-reliance on CanFaCS worker's reassurance despite concerning evidence
• non-disclosure of abuse by traumatised children living with perpetrator
• failure to follow up on children's disclosures made in Victoria
• minimal investigation by intake—reliance on perpetrator's narrative rather than verification
• interstate communication failures—Victorian DHHS disclosures not transferred to ACT CYPS
• lack of information sharing between AFP and CYPS
• extreme workload and staffing pressures in child protection intake and appraisal
• inadequate time for caseworkers and Team Leaders to review files and policy
• failure to contact schoolteachers for clarification; accepted father's implausible explanations
• inadequate supervision and mentoring of junior caseworkers
• lack of structured decision-making tools to assess risk holistically
• silencing and coaching of children by perpetrator
• absence of mandatory formalised information-sharing protocols interstate

Coroner's recommendations

1. Remove requirement for parental consent to appraise or investigate children's welfare (Recommendation 9 of Glanfield Inquiry)
2. Establish mandatory formalised information-sharing protocols and Memoranda of Understanding between ACT CYPS, AFP, Education, Health, and interstate jurisdictions
3. Create interstate liaison officer system with capacity to proactively share information; enable direct communication between interstate caseworkers
4. Introduce structured risk assessment tools (actuarial or case conference models) to replace subjective decision-making and improve consistency
5. Mandate mandatory training in family violence, domestic violence impacts on children, and cumulative harm for all CYPS staff
6. Establish national database of children at risk with real-time interstate information sharing
7. Implement active confirmation of schools' enrolment and transfer; require schools to notify child protection when children are unenrolled mid-term
8. Embed liaison officers within CYPS and schools; formalise education-child protection communication pathways
9. Establish dedicated resources for intake—reduce Team Leader caseload (600+ cases/month is unsustainable) and implement triage system with oversight
10. Require senior supervision and secondary review for decisions to close files with unaddressed safety concerns
11. Implement mandatory documentation of Section 862 information-gathering requests; escalate if requests are not completed within specified timeframe
12. Create child protection case conferences with inter-agency participation when cumulative harm is identified
13. Remove or strengthen 'consent' requirement for parental assessment when child protection concerns exist; enable assessment without perpetrator present
14. Strengthen SACAT-CYPS liaison to ensure disclosures are properly actioned and escalated
15. Establish AFP-CYPS information-sharing protocol to ensure confirmed drug use, criminal history, and DVO alerts are immediately shared
16. Implement training on recognising signs of fear-based coercion in children and how traumatised children disclose abuse
17. Enhance initial risk assessment (intake) to require review of full file history, not just 12 months; mandate verification of third-party claims
18. Establish clear protocols for interviewing alleged perpetrators—require consultation with supervisor first
19. Develop resources and referral pathways for children aged 7+ who experience neglect
20. Increase staffing and reduce workload in child protection; prioritise recruitment and retention of experienced caseworkers
21. Ensure adequate induction, training, and time to review policy for new starters to child protection roles
22. Create systems to alert to repeat injuries and bruising patterns; flag facial bruising automatically for further investigation
23. Ensure AFP shares toxicology results, police attendances, and DVO information with relevant child protection jurisdictions
24. Implement peer review or secondary reader system for intake decisions, particularly those recommending no further action
25. Establish mandatory consultation with health professionals (GPs, paediatricians, CARHU) when medical concerns arise; formalise feedback loops