Inquest into the death of Baby Q
Deceased
Baby Q
Demographics
0y, female
Date of death
2018-11-17
Finding date
2024-04-18
Cause of death
unascertained
AI-generated summary
A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental health issues. Critical failures included Queensland DCSSDS inadequately assessing an August 2018 notification of parental aggression, DCJ failing to conduct a review safety assessment after receiving information about untreated mental illness and violence, police not consistently reporting to child protection, missed opportunities to escalate to emergency services, delayed processing of reports at the DCJ helpline, and information not being shared effectively between systems. After-hours police in Queensland appropriately contacted specialist child protection units on 16-17 November but lacked resources for emergency accommodation and did not use the afterhours DCSSDS hotline. The family remained disconnected from consistent support. Multiple agencies recognised individual risk factors but failed to synthesise the cumulative picture of danger that should have triggered statutory intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- child known to child protection authorities in multiple states
- parental mental illness (father with schizophrenia, psychosis; mother with bipolar disorder or delusional disorder)
- father untreated psychosis with command hallucinations
- parental substance misuse (father alcohol dependent, cannabis user)
- family homelessness and transience
- domestic and family violence
- inadequate assessment of cumulative harm by DCSSDS
- failure of DCJ to conduct review safety assessment after receiving concerning information
- failure to escalate to afterhours DCSSDS hotline by QPS on 16-17 November 2018
- information not shared effectively across state borders and between agencies
- delayed processing of reports at DCJ helpline
- police entering information into child protection systems without alerting relevant caseworkers
- lack of emergency supported accommodation
- father's psychotic delusions that incorporated violence toward children
Coroner's recommendations
- DCSSDS to require family wellbeing services to inform DCSSDS if family disengages prematurely from service and reason for disengagement
- DCSSDS to improve access for caseworkers to expert psychological opinion when working with families with complex mental health needs
- NSW DCJ and NSWPF to amend ChildStory so Assessment Officer entries in CWU tab automatically alert relevant CSC when open file exists
- NSW DCJ and NSWPF to trial information sharing portal giving DCJ direct access to limited relevant CoPS information (criminal history, domestic and family violence)
- QPS and NSWPF to take proposal to Australian Criminal Intelligence Commission to trial NCIS information sharing portal for state and territory child protection authorities to access relevant police information nationally
Full text
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