Coroner's Finding: ROBERTS Jarrad Delroy
Deceased
Jarrad Delroy Roberts
Demographics
10y, male
Date of death
2006-10-06
Finding date
2009-05-22
Cause of death
sepsis (fusobacterium necrophorum) complicating right otitis media
AI-generated summary
Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seeing Dr M., who appropriately recommended hospital but did not insist given mother's resistance. Jarrad collapsed within 90 minutes of the consultation and died at hospital. The coroner found his death was entirely preventable with earlier antibiotic treatment. Critical systemic failures included: mother's severe untreated post-traumatic stress disorder and neglect; extremely poor living conditions; chronic school non-attendance (65 of 76 days absent in first half of 2006, then zero attendance for 4 months); Families SA receiving 20 notifications over 13 years but taking insufficient action due to resource constraints; DECS (school) making extensive efforts but unable to gain meaningful intervention; lack of coordinated response between agencies; and absence of prosecution for educational neglect despite legal provisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- delayed presentation for medical treatment (5-7 days of untreated infection)
- severe neglect and unsanitary living conditions
- mother's untreated post-traumatic stress disorder and inability to provide care
- extremely poor diet (takeaway food only)
- chronic school non-attendance not appropriately investigated
- inadequate inter-agency coordination between DECS and Families SA
- insufficient resources for child protection investigations
- failure to escalate or enforce mandatory reporting protocols
- lack of enforcement of Education Act provisions
- mother's refusal to engage with services
Coroner's recommendations
- Prosecutions should be brought for non-attendance at school under section 76 of the Education Act 1972 where there is a reasonable prospect of success
- The Children's Court should be the appropriate forum for hearing prosecutions under section 76, requiring legislative change
- DECS obtain legal advice on the status of its policy against prosecutions for school non-attendance
- Chief Executives of DECS and Families SA personally review coordination of responses to chronic non-attendance, rationalise resources, and eliminate demarcation between agency roles through seamless cooperation
- Better coordination between DECS and Families SA in investigating persistent non-attendance as an indicator of child risk
- Revision of Memorandum of Understanding between DECS and Families SA as it is misconceived and creates confusion
- Forward copy of finding to Commonwealth Minister for Families, Housing, Community Services and Indigenous Affairs with offer of access to transcript and exhibits
- Consider income management regime provisions (Social Security Administration Act) as potential incentive for parents to ensure school attendance
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