S

Contributing factors

• placement outside service agreement without adequate safeguards
• insufficient risk assessment of absconding behaviour
• inadequate communication between departments regarding child conflict
• failure to communicate incident reports to Department
• incomplete assessment and admission paperwork at residential facility
• poor internal communication systems at care facility
• insufficient staff training and orientation at residential facility
• inadequate monitoring of residential facility by Department
• poor coordination of police search operation
• inadequate risk assessment by police
• failure to escalate to Search and Rescue procedures
• lack of incident command training for acting duty officer
• poor communication between duty officer and communications centre
• insufficient broadcast of missing person alert
• delay in notification that children were missing
• focus on crisis with aggressive resident rather than locating missing children

Coroner's recommendations

1. Department review processes for placing children outside service agreements and develop management plans with close monitoring before placement
2. Department develop ICMS field recording past conflict/relationship issues between children for accessibility by CSOs and PSUs
3. Department review and implement formal carer feedback mechanism following placements
4. Department review reporting requirements by carers and facilities and streamline processes; conduct regular audits of care facility policies, procedures, communications and staff training
5. Department ensure supervision review of kinship care investigations and timeframes
6. Lifestyle Solutions ensure monitoring and internal review processes for policies, procedures, communications and staff training across all centres
7. QPS ensure all acting DDOs complete Incident Command Training or at least SAP preparatory module
8. QPS revise OPM sections 12.5 and 17.5 and map Rockhampton SOP to clarify medium risk incident management and escalation
9. QPS consider facility to permit 000 call monitoring and involvement of persons other than call taker
10. QPS revise communication procedures between DDO and Comco to ensure status awareness and consultation before reallocation of resources
11. QPS increase frequency of BOLF broadcasts for vulnerable missing persons
12. Department develop audit tool for examining start-up organisation policies, procedures and compliance in initial phases of residential facility operation