Inquest into the death of BW

Contributing factors

• emergency removal of child by police
• depression and anxiety
• alcohol misuse and intoxication
• lack of mental health assessment by police
• inadequate interagency communication between NSW Police and DCJ
• delayed DCJ case allocation and home visit
• COVID-19 pandemic impact on support services and agency capacity
• parental distress following child removal
• absence of immediate casework support following removal
• police lack of training in parental welfare during emergency removals
• junior officer deference to hierarchy preventing escalation of suicide threat information

Coroner's recommendations

1. Office of the Senior Practitioner give consideration to what further policy guidance and practical assistance the Department can provide to NSW Police in respect of conduct of removals of children pursuant to s 43 Care Act
2. NSW Police notify DCJ as soon as reasonably practicable of any determination to exercise police power to remove a child, with priority access to DCJ Child Protection Helpline
3. NSW Police Force Handbook and Operations Manual be reviewed to enhance police knowledge on conduct of emergency removals, including content on separation and loss, support during removal, helping children make sense of removal, and assuming care of child
4. NSW Police review publications and training resources on emergency removals, having regard to DCJ Removal or Assumption of a Child Mandate and Separation and Loss Practice Advice
5. NSW Police consider delivery of training sessions to appropriate class of officers, including by online means, on conduct of decisions to remove children pursuant to s 43 Care Act
6. NSW Police Commissioner review Prioritising Police Response to Incidents policy and guidance material to ensure consistency with amended Radio Operations Group Standard Operating Procedure requiring all incidents involving threat of self-harm be assigned Priority 2 response
7. NSW Police Academy education and training prior to attestation be reviewed to ensure adequate instruction on importance of junior officers raising relevant information directly with supervisors
8. Joint creation by NSW Police and DCJ of fact sheet required to be given to parent at time of emergency child removal, including why removal occurred, what happens next, DCJ Helpline details, police officer contact details, Legal Aid NSW contact, complaint procedures, and 24/7 mental health support services
9. Interagency Guidelines on Reporting and Responding to Child Wellbeing and Safety Concerns be jointly reviewed to include reference to police exercise of power under s 43 Care Act with hyperlinks to relevant NSWPF policies