CJ - Non-inquest findings

Contributing factors

• Exposure to domestic and family violence perpetrated by father
• Physical abuse by father including strangling, dragging by hair, punching, force-feeding, head shoved down toilet, thrown from truck
• Alleged sexual abuse by father
• Cumulative childhood trauma
• Unaddressed suicidal ideation and self-harm behaviours
• Lack of access to mental health services despite clear need
• Rejection by both parents
• Parental separation and family instability
• School suspensions and academic disengagement
• Undiagnosed and unsupported ADHD and depression
• Substance use (cannabis, alcohol)
• Systemic failure to apply domestic and family violence lens to case planning
• Absence of trauma-informed child protection practice
• High staff turnover and inconsistent case management
• Inadequate coordination between Child Safety Services, mental health services, and school
• Failed attempts to access specialist assessment

Coroner's recommendations

1. Consistent implementation of domestic and family violence informed child protection practice across all Queensland child safety service centre locations
2. Ongoing investment in upskilling frontline practitioners and leadership in domestic and family violence and trauma-informed practice
3. Enhanced training in identifying and responding to trauma and cumulative harm in child protection practice
4. Coordinated response between Child Safety Services and Queensland Health to address acute mental health needs of young people deemed at suicide risk
5. Improved capacity and resourcing of specialist mental health services for young people affected by domestic and family violence, as identified as a key priority in the National Plan to End Violence Against Women and Children
6. Better information sharing, consultation and collaboration between Child Safety Services and schools regarding vulnerable children
7. Implementation of structured processes to ensure continuity of care management and reduce worker inconsistencies
8. Development of integrated support networks that are coordinated and holistic rather than siloed
9. Application of trauma-informed assessment and response frameworks that understand problematic behaviours in the context of underlying trauma rather than deficit-focused approaches
10. Recognition of the impact of domestic and family violence on parental capacity and provision of recovery support to parents rather than victim-blaming responses