Inquest into the death of Emily

Contributing factors

• early childhood trauma and welfare concerns prior to foster care
• attachment issues and insecure sense of belonging
• anxiety and panic attacks from early childhood
• divided loyalties between birth and foster families
• placement of short-term foster children undermining sense of security
• deteriorating behaviour in adolescence not adequately supported
• incomplete sharing of medical and psychological histories with treating clinicians
• lack of information transfer to new school
• adoption process put on hold without adequate therapeutic support
• failure to recognise cumulative serious risk factors in final year of life
• inadequate coordination between FACS and out-of-home care NGO

Coroner's recommendations

1. Reintroduce written forms when children are seen by external clinicians, including details of the OOHC NGO's role, relevant past treatments, and clinician diagnoses
2. Review policies to require written reports from external clinicians for significant attendances
3. Proactively share relevant previous clinician reports with external clinicians
4. Invite external clinicians to participate in multidisciplinary case conferences
5. Require written information be provided to schools regarding significant past and emerging issues affecting safety and welfare, including mental health practitioner details
6. Request written information from schools when child transfers to ensure continuity of information
7. Invite school representatives to multidisciplinary case conferences
8. Develop training package for foster carers specific to transition to adolescence
9. Develop training regime preparing foster carers for various milestones in advance
10. Develop policies on communicating significant decisions to children in care with guidance and clinical support
11. Update parent information book with guidance on communication supporting sense of belonging and social media issues
12. Develop social media fact sheets for foster parents and children
13. Review carer training to include anticipating adolescent oppositional behaviour, understanding underlying trauma, and strategies for seeking clinical support
14. Circulate recommendations to all NGOs providing OOHC in NSW to review policies and procedures