Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

Contributing factors

• Severe iron deficiency anaemia due to diet limited to milk, yoghurt and pureed foods with minimal iron content
• Feeding difficulties and food aversion preventing adequate nutritional intake
• Failure to thrive with progressive weight loss and muscle wasting
• COVID-19 infection placing additional strain on compromised cardiorespiratory system
• Parental overwhelm from multiple psychosocial stressors including poverty, housing insecurity, mental health issues, and substance use
• Parental inability to action medical referral despite having letter recommending GP assessment
• Missed opportunity by Child Safety to arrange expedited medical assessment during home visit despite obvious signs of severe anaemia
• Delayed commencement of Child Safety Investigation & Assessment due to high caseloads
• Aspiration pneumonia secondary to anaemia

Coroner's recommendations

1. Child Safety to prioritise expedited medical assessment through SCAN referrals when assessing young children with health or developmental concerns during Investigation & Assessment phase
2. Child Safety to strengthen practitioner training on recognising vulnerability factors in infants and young children and understanding how quickly they can deteriorate
3. Child Safety to ensure application of written guidance in the Child Safety Practice Manual regarding when medical examination or specialist assessment may be necessary, including for young children showing poor feeding, lethargy, or physical signs of ill-health
4. Child Safety to enhance practitioner awareness of cognitive biases such as the 'halo effect' that can lead practitioners to overestimate parents' capacity when they appear cooperative and engaging
5. Queensland Government to invest in comprehensive practice guide on recognising parental substance use and its impact on children, incorporating risk indicators, safety planning mechanisms and intervention thresholds
6. Queensland Health to develop guidelines for clinicians on family-centred approach allowing direct referral of siblings when health concerns are identified (though CHQ determined this was not consistent with current service implementation standards)
7. Child Safety to continue developing and strengthening training on assessing risk in families with problematic parental substance use
8. Child Safety to ensure practitioners seek information from Alcohol and Other Drugs professionals to inform assessment of parental substance use and parenting capacity
9. Child Safety to ensure adequate resourcing to prevent delays in commencing Investigation & Assessment phase