Inquest into the death of KBS
Deceased
KBS
Demographics
1y, male
Date of death
2019-01-13
Finding date
2025-08-28
Cause of death
Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrhage
AI-generated summary
A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned burns consistent with inflicted injuries sustained over time. The child died in the early hours of the morning after receiving a significant blunt force blow to the abdomen. Family and support services were involved but were unaware the mother's partner (who had a history of violence) was living in the home. Child protection agencies did not conduct a full safety assessment following his father's incarceration and were not notified of the household composition change. No charges have been laid; the coroner found insufficient evidence to determine manner of death and referred the case to NSW Police Unsolved Homicide Unit.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inflicted blunt force trauma to abdomen
- Failure of child protection services to conduct full safety assessment after father's incarceration
- Failure to assess risk posed by mother's undisclosed partner with history of violence
- Partner's undisclosed presence in household
- Lack of knowledge by support agencies of household composition change
- Limited statutory authority of voluntary support program to access home
- Email communication failure between Mission Australia and DCJ
- Mother's fear of partner limiting disclosure to authorities
Coroner's recommendations
- Refer death to NSW Police Unsolved Homicide Unit for ongoing investigation in accordance with protocols and procedures of that unit
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