Inquest into the death of Deborah Leanne Melville

Contributing factors

• failure of foster carer to seek medical treatment despite obvious signs of serious illness
• failure of FACS to conduct regular home visits as required by law
• failure to conduct mandatory three-monthly case reviews
• failure to properly re-register foster carer or verify standards of care
• inadequate monitoring of kinship/family carers (perceived as low priority)
• systemic staffing shortages and caseworker burnout
• poor continuity of caseworkers (5 caseworkers in relevant period)
• inadequate case supervision
• deficient computerised case management system
• failure to identify patterns of cumulative neglect
• foster carer's full-time employment combined with serious gambling problem and relationship breakdown
• loss of stable carer support (partner absence)
• housing instability (property loss)
• overcrowded inadequate housing conditions
• cultural misconceptions about acceptable standards of care for Aboriginal children
• absence of objective criteria for adequate standard of care
• poor handover between caseworkers leading to loss of corporate knowledge

Coroner's recommendations

1. Care and Protection of Children Act 2008 be amended to require a child under CEO care be visited at least once every 2 months
2. Regulations be promulgated specifying basic standards of care for placement arrangements
3. Section 70 be amended to require care plans refer to standards of care specified in Regulations
4. Section 74 be amended to require assessment of carer compliance with basic standards in six-monthly reviews
5. Section 12 be amended to require Aboriginal children's carers meet basic standards of care
6. Consider regular court review of protection orders
7. Part 5.1 be amended for 2-yearly review of Act administration and enhanced Children's Commissioner powers
8. Section 15 be amended to define 'cumulative harm'
9. FACS staff receive training on identifying and dealing with cumulative harm
10. FACS develop written handover system with summary of risk factors when caseworker changes
11. FACS enhance computerised information system for easy identification of 'red flag' issues
12. FACS notify NT Police of names and addresses of carers and develop protocol for information sharing
13. Carer application forms be amended to include history of all children previously in applicant's care
14. FACS provide sufficient administrative support to allow caseworkers to focus on core child protection duties