Inquest into the death of Jade

Contributing factors

• medical neglect - failure to seek timely medical attention despite respiratory symptoms
• squalid living conditions with hazards including cockroaches, broken glass, rotting food, and poor hygiene
• parental capacity issues including untreated mental health conditions in mother and untreated mental health and substance misuse issues in father
• domestic violence in the home
• social isolation of mother
• inadequate nutrition and hydration
• mother's own history of childhood abuse and neglect
• dehydration and malnutrition contributing to sepsis and renal failure
• lack of parental recognition of illness severity

Coroner's recommendations

1. To the Chief Executive, The Benevolent Society: The Benevolent Society review the training, and messaging, to TBS Brighter Futures practitioners around the need for strict compliance with the mandatory reporting obligations under the CYP Act having regard to these findings.
2. To the Secretary: The Secretary consider issuing a directive to all Brighter Futures' providers emphasising strict compliance with mandatory reporting obligations having regard to these findings. As part of recommissioning all family preservation services DCJ should, having specific regard to these findings and recommendations made in this inquest, recognise and emphasise that family preservation providers hold mandatory reporting responsibilities under the CYP Act, reflecting this in contracts, program specifications and other program implementation documentation and activities.
3. To the Minister for Families and Communities: The Minister review these findings and examine the caseworker capacity of the Muswellbrook CSC and consider the other issues canvassed in these findings.