Inquest into the death of Michael Chisholm, Aaliyaha Webb and Julian Chisholm

Contributing factors

• Police failure to examine documentation at first point of contact
• Incorrect coding of complaint (welfare check instead of child welfare)
• Delayed police response due to low-priority grading
• Undiagnosed depression and mental health crisis in perpetrator
• Unresolved custody proceedings causing financial and emotional stress
• Accumulated debts and legal bills
• Lack of escalation by family members despite expressed concerns
• Absence of mental health intervention despite warning signs

Coroner's recommendations

1. Amendment of section 126(2A) of the Police Administration Act to insert paragraph (ba) empowering a police member to enter a place if reasonably believed necessary to evaluate whether there is a serious imminent risk to the welfare of a child
2. Employment of a dedicated Grief Counsellor to assist families whose loss is subject to coronial investigation, with broader role in other deaths under police investigation
3. Reinforcement of Call Centre Operator responsibility to consult Standard Operating Procedures (including placement of reminder signs)
4. Amendment of Standard Operating Procedure 423 (Child Welfare) to include prompts for open-ended questions to elicit specific caller concerns such as neglect, cruelty, violence, sexual abuse, or removal from jurisdiction