Inquest into the death of Riley Christopher Shortland

Contributing factors

• failure to transfer comprehensive behaviour support plan and risk information from HWNS to DCJ during case management transition
• failure of DCJ case workers to review Riley's file upon receiving it
• rushed and inadequate respite arrangement without proper needs assessment
• incomplete information provided to SNAP regarding Riley's transport needs and requirement for two carers
• SNAP failed to actively seek detailed information about Riley's needs and behaviours
• inadequate carer-to-child ratio (1:1 instead of required 2:1)
• excessive working hours for support worker (27.5 hours continuously without adequate rest)
• inappropriate supervision arrangements where support worker monitored child during sleep rather than receiving uninterrupted rest
• absence of secondary carer during transport despite documented extreme risk in traffic and vehicle travel
• communication failures across multiple agencies
• task-focused rather than child-focused case management by DCJ
• use of inadequate and non-compliant restraints (Houdini strap and too-small booster seat)

Coroner's recommendations

1. Office of the Children's Guardian should require organisations providing specialised substitute residential care and substitute residential care to have transport policies with assessments of each client's transport needs and requiring driver plus dedicated carer for children requiring 1:1 support or with behaviours of concern during transportation
2. Office of the Children's Guardian should engage with DCJ to devise an appropriate checks and balance assessment sheet for potential special care providers
3. DCJ should devise a checks and balance assessment sheet for potential special care providers to ensure individual needs can be met
4. DCJ should devise policy or procedure setting out minimum paperwork to travel with a child in special care placement
5. DCJ should make enquiries with Mobility and Accessibility for Children in Australia Ltd (MACA) to explore assistance in formulation of transport policies and Safe Travels learnings, particularly regarding safety harnesses for children with autism
6. DCJ should consider making available to organisations delivering SSRC or supporting children with autism the Safe Travels learnings following successful trial and rollout
7. SNAP should review and amend or draft staffing policy addressing hours employees may work, preventing any employee being rostered for more than a double shift (two 8-hour shifts or sleep-over shift of 4hrs + 8hrs sleep + 4hrs) plus a further 8-hour shift without a 10-hour break
8. SNAP should seek support of independent third-party advisor to deliver sessions on risk implications of staffing levels and regulatory requirements and to assess appropriateness of staffing policy
9. SNAP should develop policy for staff to elevate concerns about staffing challenges independent of executives and managers
10. SNAP should ensure PART training or similar becomes part of cyclic refresher training program for all staff and new employees soon after probation
11. SNAP should update transport policy to include: providing driver with contact details of available support person; prohibition on driver exiting vehicle alone on motorway/highway/major corridor except emergencies; prohibition on opening vehicle door to access child alone on motorway/highway/major corridor except emergencies; requirement to contact emergency services or support person for safe access when child presents risk to safe driving or self