Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

Contributing factors

• Parental methylamphetamine use during three-day drug binge
• Inadequate fluid and food provision for eight days prior to death
• Delayed commencement of Investigation & Assessment (six weeks)
• Lapse in Child Safety engagement due to officer's emergent leave without case reallocation
• Failure to implement planned urine drug screening
• Unidentified interstate child protection history indicating pattern of substance-use related neglect
• Lack of external monitoring during periods of disengagement
• Insufficient medical input to child protection assessment
• New partner's involvement and substance use escalation
• Absence of SCAN referral despite complexity
• Inadequate response to emerging pattern of parental disengagement and avoidance
• No visibility of observations from daycare, neighbours, and family regarding deterioration
• Child Safety officers did not observe external indicia of substance use during April-June 2019
• Missed opportunities to strengthen assessment with doctor information and observations of physical appearance
• Heat exposure (heater on in closed room for 21 hours)

Coroner's recommendations

1. Examination of Child Safety resourcing to provide early assertive intervention for families where parents have problematic substance use
2. Strengthening of Child Safety practice regarding recognition of parental substance use and its impact on children, particularly methylamphetamine use
3. Improved training for Child Safety practitioners to recognise risk indicators of severe neglect and failure to thrive in infants
4. Development of comprehensive practice guidance incorporating identifiable risk indicators, safety planning mechanisms and wraparound services for children whose parents have problematic substance use
5. Integration of specialist medical input and SCAN referral processes into child protection assessment and decision-making for complex cases involving health and neglect concerns
6. Improved access to and use of interstate child protection history information through Connect for Safety and Unify systems
7. Enhancement of handover procedures between I&A and IPA teams to ensure continuity and accountability during transition phases
8. Strengthened attention to emerging patterns of parental disengagement and avoidance, particularly during transition phases of Child Safety involvement
9. Implementation of mandatory triggers for more intrusive intervention when parents fail to engage with contact visits or when Child Safety officers cannot sight children
10. Improved communication protocols between Child Safety and Queensland Health services to ensure timely exchange of clinical information
11. Examination of Child Safety practice in the forthcoming Commission of Inquiry with particular focus on resourcing, assessment of infants at high risk, and management of parental substance use cases