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Lee, Mason Jet

Deceased

Mason Jet Lee

Demographics

1y, male

Coroner

Bentley

Date of death

2016-06-11

Finding date

2020-06-02

Cause of death

Abdominal injuries (perforation of small bowel and mesentery with peritonitis progressing to sepsis)

AI-generated summary

Mason Lee, aged 22 months, died on 11 June 2016 from abdominal injuries inflicted by his mother's partner, William O'Sullivan, combined with severe neglect. Mason was admitted to hospital in February 2016 with severe perianal injuries and cellulitis, consistent with abuse and neglect. Despite clear medical evidence of serious harm, the Department of Child Safety failed fundamentally to protect him. Key failures included: CSOs not reading available information before making critical decisions; failure to sight Mason adequately during required face-to-face contacts; failure to investigate Mr O'Sullivan's severe mental health history and violence despite available records; closure of the case to SCAN without implementing recommendations; and catastrophic failures by the final CSO (CSO6) who saw the family but did not know she was working the case, did not sight Mason, and failed to act on critical information that he was being held hostage by O'Sullivan. A critical opportunity was missed when Mason failed to attend a scheduled hospital appointment on 7 June 2016—had he been taken, surgery likely would have saved his life.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsinfectious diseasesemergency medicineforensic medicine

Error types

diagnosticsystemcommunicationdelay

Drugs involved

methamphetamineamphetamine

Clinical conditions

abdominal perforationperitonitissepsissevere cellulitisperianal injuriesjacquet's dermatitisspiral fracture of left tibiaanaemiadehydrationshock

Contributing factors

Failure to sight child during mandatory face-to-face contacts
Failure of child safety officers to read available information about family
Failure to investigate perpetrator's (O'Sullivan's) serious mental health history and domestic violence
Failure to implement recommendations from SCAN meeting
Inadequate supervision and management of child safety officers
Failure to follow-up on missed hospital appointment
Closure of SCAN case without verification of recommendations implemented
Lack of handover between child safety officer and allocated worker
Domestic violence not adequately considered as risk factor to child
Parental deception and disguised compliance not detected

Coroner's recommendations

Amend SCAN manual and relevant legislation, policies and procedures to mandate that external support workers (e.g. RAI/IFS providers) must be invited to all SCAN meetings and information must be shared with them
Queensland Health implement formal policies and procedures for medical officers to escalate cases where they disagree with department decisions regarding child discharge from hospital
Review policies for provision of information to Queensland Police Service to ensure timely provision without redactions; QPS to report annually for three years on number of search warrants executed on department for information provision
Amend SCAN manual to require cases remain open until recommendations are verified as fulfilled or no longer appropriate
Amend SCAN manual to mandate that inquorate SCAN meetings still proceed with case planning discussion by available members
Department review policies to ensure adoption is routinely and genuinely considered as permanency option for children under 3 years where reunification is unlikely, in accordance with Carmody Inquiry Recommendation 7.4
Government consider whether Adoption Act 2009 (Qld) should be amended to reflect NSW 2018 amendments expecting permanent placement within 24 months of entering care
Department report to Coroners Court on adoption numbers and details every six months for five years

Full text

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Source and disclaimer

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