T, an eight week old infant - Non-inquest findings

Contributing factors

• maternal active drug use (amphetamines, methamphetamine, methadone)
• maternal fatigue and excessive daytime sleepiness
• co-sleeping despite medical warnings against unsafe sleep practices
• mother documented falling asleep repeatedly on or near infant
• inadequate supervision by child protection services
• failure to remove child from unsafe maternal care
• infant's special care needs (tongue tie, poor feeding, drug withdrawal symptoms)
• father's frequent absence due to FIFO work
• lack of inter-agency communication between health and child protection

Coroner's recommendations

1. The Region will work with Regional Intake Service and CSSC staff to reflect on learnings and implications for future practice
2. Practice Leadership Unit to facilitate workshops with RIS staff across Queensland to reflect on learnings from this and other reviews
3. Department provide training to Child Safety Officers and Team Leaders in assessment of information related to drug use and how to gather reliable information in investigation and assessment of substance use issues
4. Department review training provided regarding assessment of information from different categories of notifiers and weight given to professional notifier information
5. Department arrange review-reflection process with Logan Hospital to share learnings and identify processes for future engagement
6. Comprehensive professional development for CSO1, CSO3, CSO4 and TL1 regarding assessment, recording of information, and investigation and assessment skills
7. A Health Liaison Officer position was created at Logan Hospital to facilitate communication between hospital and Logan Central CSSC