Coroner's Finding: Rigney, Amber Rose and Mitchell, Korey Lee

Contributing factors

• Systemic failure of child protection authority to comply with mandatory statutory obligations
• Repeated failure to investigate notifications meeting statutory risk thresholds
• Use of 'Notifier Only Concern' (NOC) procedure to close notifications inappropriately
• Use of 'Closed No Action' (CNA) procedure due to alleged resource constraints despite statutory obligations
• Failure to escalate Tier 2 notifications to Tier 1 despite clear indicators of imminent danger
• Failure to apply for court-ordered drug assessment under section 20(2) of Children's Protection Act despite repeated credible notifications of mother's illicit drug abuse
• Failure to investigate school truancy despite child being persistently absent (statutory indicator of risk)
• Failure to investigate family homelessness despite child having no fixed address (statutory indicator of risk)
• Failure to involve police in investigation of alleged drug dealing and use
• Failure to communicate with paternal grandparents who expressed willingness to care for children
• Failure to intervene in Federal Circuit Court proceedings despite court requests and expressed concerns
• Resource constraints within Elizabeth office of Families SA cited as justification for inaction, though Gawler office had capacity
• Delayed processing of email notifications (eCARL) not assessed for days or weeks
• Disregarding of previous coronial findings in Valentine and Napier inquests regarding identical failures
• Non-adherence to Chief Executive directive following Valentine finding requiring strict compliance with section 20(2)
• Inadequate assessment of cumulative harm and historical context of mother's violence toward child S
• Mother's physical violence toward previous partner and alcohol/drug use while intoxicated in presence of children
• Mother's poor parenting capacity and lack of engagement with child protection services
• General dysfunction and neglect within family environment

Coroner's recommendations

1. A comprehensive review of all coronial and other recommendations (including from Ombudsman and Royal Commission) relating to child protection in South Australia, with a view to implementation
2. A complete review of all statutory obligations contained within the Children and Young People (Safety) Act 2017 to ensure Department practices align with obligations
3. Examination of all documented and undocumented internal Departmental procedures to ensure compliance with statutory obligations
4. Assessment and full resourcing of all statutory obligations under the Children and Young People (Safety) Act 2017 to enable duties and obligations to be carried out without exception
5. Reminder to all Department staff of the need to consider engaging police powers pursuant to the Children and Young People (Safety) Act 2017, particularly where allegations involve illicit drug abuse placing a child at risk
6. Agreement with recommendations made by the South Australian Ombudsman regarding information sharing and disclosure where necessary to prevent serious risk to health and safety of a person