Inquest into the death of Braxton Slager

Contributing factors

• Inadequate home safety assessment before placement
• Unregistered non-compliant swimming pool
• Unsafe backyard environment with dangerous materials
• Lack of supervision and inadequate baby gates
• Carer emotional distress and inadequate support from agency
• Inadequate risk assessment during emergency placement
• Failure to conduct formal home inspection at placement
• Inadequate information systems within Life Without Barriers
• Presence of unexplained cyproheptadine in child's system
• Flawed temporary care agreement process

Coroner's recommendations

1. Life Without Barriers and other Out of Home Care providers should offer psychological evaluation and support to foster carers when they cease caring for a foster child after an extensive period, before any new child is placed. This should be a condition of accreditation with the Office of the Children's Guardian.
2. Life Without Barriers should provide copies of these findings and supporting documents to the Office of the Children's Guardian for reaccreditation purposes.
3. The State Director of Life Without Barriers should provide copies of findings and supporting documents to the Board of Directors and advise the Coroners Court when done.
4. Where FACS retains care and case management responsibility, FACS should undertake a joint visit with the accredited agency and carers at the home to assess suitability, ensure child settling, and allow carers to raise issues with both FACS and the agency.