Coroner's Finding: Johnstone, BJay

Contributing factors

• Severe physical abuse by father
• Multiple episodes of head trauma
• Failure of Child Protection Services to properly assess risk and implement protective measures
• Failure to complete Tasmanian Risk Framework assessment
• Overlooked critical early notification on 10 August 2012
• Premature closure of CPS notification
• Inadequate home safety assessment before discharge from hospital
• Inappropriate referral to Gateway support services without completion of risk assessment
• Failure of Tasmania Police to prioritise and investigate report received 29 October 2012
• Exposure to family violence and drug abuse in home environment
• Mother's incapacity to protect due to intimate partner violence and control
• Grandmother and uncle's failure to remove child from perpetrator

Coroner's recommendations

1. Implement comprehensive training regime for all CPS workers in Tasmanian Risk Framework, CPS Practice Manual and Specialist Guides with regular updates
2. Conduct comprehensive independent review of CPIS functionality and usage including accessibility and worker confidence
3. Implement audit and quality assurance system to determine whether TRF is routinely and correctly used and risk assessments accord with statutory responsibilities
4. Implement audit system for unborn baby notifications state-wide to ensure proper investigation and actioning in timely manner
5. Develop child protection liaison officer positions in North and North West Tasmania with duties including hospital staff consultation, liaison between agencies, and management of unborn baby alert process
6. For infants under six months with bruising notifications, arrange examination by paediatrician or suitably qualified medical practitioner to determine if non-accidental
7. Provide all notifiers with electronic receipt for all notifications
8. Continuously review working and constitution of Three and Under Panel to ensure effectiveness
9. Where notification referred to Gateway, ensure Gateway receives completed TRF and provides to IFSS organisations
10. Conduct formal review of CBIS system functions focusing on capacity to manage CPS referrals, statutory and organisational environment, timeframes for risk assessments, adequacy of CAF tool, need for home visits in higher risk cases, document sharing procedures, and quality assurance
11. Implement regular training for CPS, Gateway and IFSS workers on rarity and significance of infant bruising, risk factors for family violence, detection of family violence, risk factors of cannabis use, and effective questioning of parents
12. Implement joint training between CPS, Gateway and IFSS on risk assessment including TRF, CAF and family violence matters
13. Consider amendments to Children, Young Persons and Their Families Act 1997 to provide increased powers where child at risk due to parental drug abuse including orders for treatment and periodic testing
14. Incorporate recommendations into CPS Redesign Reference Group and Vulnerable Infant Strategy with staged implementation and monitoring
15. Strengthen protocols between agencies to identify at early stage high risk perpetrators of family violence who may perpetrate child abuse
16. Tasmania Police to identify need for training and education regarding reports of child abuse on electronic referrals to CPS, Police Manual and MOU requirements, mandatory reporting requirements, and prioritising investigation of such reports
17. Implement training programs for police officers on child abuse reporting if need identified, maintained on regular basis
18. Review role of Crime Management Unit in vetting information reports regarding child abuse and creation of electronic CPS referrals with view to enhancing and standardising role across state