Inquest into the death of BL GN and D G

Contributing factors

• unsafe sleeping environment with soft items and pillows in cot
• maternal ice addiction and drug use during pregnancy and postpartum
• inadequate parental supervision due to drug intoxication
• chaotic household environment
• failure of child protection services to assess and allocate cases
• repeated case closures for 'competing priorities' without proper risk assessment
• lack of home visits and safety assessments despite multiple reports
• maternal cognitive impairment related to drug withdrawal
• possible congenital cardiac abnormality (in second child)

Coroner's recommendations

1. FACS undertake a review of types of ROSH reports currently allocated, referred or closed for competing priorities at triage so FACS Executive can monitor resource allocation and address procedural changes
2. FACS require all Managers Client Services to use Resource Management Dashboard to report to Director Community Services on: (a) children with open plans and no triage activity for over 28 days; (b) children where ROSH reports were closed after 28 days
3. FACS Quarterly Business Review include: (a) monitoring of serious case review recommendations; (b) monitoring of group supervision compliance; (c) measurement of volume and geographic data of ROSH reports closed at each CSC
4. On every FACS Serious Case Review Panel for child death, undertake critical assessment of applicable policies and comment on deficiencies in drafting, implementation and compliance
5. FACS urgently amend policies for allocation of unallocated ROSH reports to provide: (a) reports cannot be closed before assessment at WAM; (b) if unallocated, record in Dashboard and notify Director; (c) closure only after triage assessment, WAM consideration, Director notification, and consideration of alternatives; (d) closure cannot occur for 'competing priorities' before WAM assessment