Inquest into the death of ML

Contributing factors

• unsuitable emergency accommodation without heating, hot water or functioning appliances
• parental domestic violence and separation of family from protective services
• inadequate recognition of child's deteriorating health over days prior to death
• systemic failures in child protection case management and interagency communication
• chronic staff shortages and excessive caseloads in DCJ preventing adequate supervision
• failure to implement proper case transfer procedures between DCJ offices
• lack of meaningful liaison between DCJ, Community Corrections and Police in November 2019
• parental substance use and mental health issues affecting capacity to recognize child illness
• absence of culturally appropriate Aboriginal consultation and support
• inadequate safety assessments that did not account for cumulative impact of family violence

Coroner's recommendations

1. Broad systemic changes required by DCJ including filling excessive staff vacancies
2. Improved systems and training to staff at DCJ
3. Enhanced staff resourcing and policy improvements at DCJ
4. More proactive approach to multiagency cooperation throughout NSW, particularly in rural and regional areas
5. Establishment of formal Aboriginal consultation processes as standard practice rather than ad-hoc arrangements
6. Improved case transfer protocols requiring in-person handover meetings between caseworkers with documented transfer notes
7. Regular mandatory training for DCJ staff on intergenerational trauma, domestic violence impacts, and culturally responsive practice
8. Enhanced liaison procedures between DCJ, Community Corrections and Police to share information about at-risk families
9. Investment in sustainable interagency programs rather than trial-and-abandon approaches
10. Development of culturally appropriate support services for high-risk Aboriginal families in regional areas
11. Improved housing coordination between Community Corrections and relevant agencies to prevent families accessing unsuitable emergency accommodation