Coroner's Finding: ROBERTS Jarrad Delroy

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

1. 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
2. The Children's Court should be the appropriate forum for hearing prosecutions under section 76, requiring legislative change
3. DECS obtain legal advice on the status of its policy against prosecutions for school non-attendance
4. 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
5. Better coordination between DECS and Families SA in investigating persistent non-attendance as an indicator of child risk
6. Revision of Memorandum of Understanding between DECS and Families SA as it is misconceived and creates confusion
7. Forward copy of finding to Commonwealth Minister for Families, Housing, Community Services and Indigenous Affairs with offer of access to transcript and exhibits
8. Consider income management regime provisions (Social Security Administration Act) as potential incentive for parents to ensure school attendance