Inquest into the death of AW
Deceased
AW
Demographics
2y, female
Date of death
2018-04-14
Finding date
2023-10-24
Cause of death
effects of fire (smoke inhalation and thermal injury)
AI-generated summary
AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact cause could not be determined despite expert investigation; electrical fault, accidental ignition, or deliberate lighting remained possible. The inquest revealed critical failures in child protection services: the Department of Communities and Justice (DCJ) had received 32 risk reports, 23 screened as high-risk concern, yet ceased involvement in September 2017. An Internal Child Death Review found DCJ caseworkers focused too narrowly on incidents, failed to recognise cumulative and escalating risk patterns, and should not have disengaged. Contributing factors included poor housing conditions (old timber construction, inadequate electrical wiring, non-compliant smoke alarm positioning), parental substance use, pending eviction, and inadequate child supervision. While systemic failures were criticised, the coroner could not determine whether the death was preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Contributing factors
- failure of child protection services to identify and respond to ongoing cumulative risk
- inadequate casework assessments focusing on incidents rather than patterns and history
- inappropriate cessation of DCJ involvement in September 2017 despite high-risk assessment
- poor housing conditions including old timber construction and inadequate electrical system
- smoke alarm positioned non-compliantly on top of refrigerator rather than on ceiling
- possible electrical fault in house wiring system
- parental substance use affecting ability to respond effectively to fire
- inadequate supervision and protection of child
- pending eviction notice served two days prior to fire
- exposure to multiple environmental safety hazards
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