Inquest into the death of DB
Deceased
DB
Demographics
2y, female
Date of death
2016-12-20
Finding date
2025-05-01
Cause of death
sequelae of blunt force head and spinal cord injuries
AI-generated summary
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: accepting ROSH reports were 'malicious' without proper investigation; referring to Brighter Futures prematurely after superficial assessment; failing to conduct risk assessments after subsequent ROSH reports; not obtaining NSW Health or Police records; not arranging professional medical assessments; and critically, closing the case on 19 August 2015 without adequate safeguards. A toxic workplace culture at Bankstown CSC, inadequate supervision by the manager, and confusion about roles between DCJ and Brighter Futures staff contributed. The coroner recommended DCJ develop guidance on accessing audio Helpline recordings to assist caseworkers in assessing complaint credibility. Key lesson: statutory child protection responsibility cannot be delegated; systemic failures in assessment, supervision, and decision-making endangered a vulnerable child.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- premature referral to Brighter Futures without adequate assessment
- acceptance of ROSH reports as 'malicious' or 'vexatious' without investigation
- failure to conduct risk and safety assessments after second and subsequent ROSH reports
- failure to obtain NSW Health and NSW Police records
- failure to arrange professional medical assessments for the children
- confusion about roles and responsibilities between DCJ and Brighter Futures staff
- delay in DCJ home visit after third ROSH report
- inadequate information provided to Brighter Futures in referral
- failure to verify concerns raised in ROSH reports
- inappropriate case closure on 19 August 2015 without proper assessment
- failure to transfer case to appropriate district
- inadequate supervision of caseworker by manager
- lack of oversight by senior management
- toxic workplace culture at Bankstown CSC
Coroner's recommendations
- DCJ consider developing guidance for child protection workers which: (a) informs caseworkers and their managers of the availability of the audio Helpline reports; and (b) provides managers with assistance to make decisions about when it may be appropriate for audio Helpline reports to be made available to support decision making
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