Coronial
TASother

Coroner's Finding: Infant Deaths

Finding date

2021-09-17

Cause of death

varied: sudden unexpected death in infancy (unsafe sleeping environment); drowning; acute pneumonia; bronchopneumonia; blunt force trauma from motor vehicle crash

AI-generated summary

Coroner's joint inquest into deaths of seven children (six infants and one child aged 16 years) between 2014 and 2018 in Tasmania. All families had history of Child Safety Services (CSS) involvement. Coroner found no direct causal link between CSS action/inaction and any death; however, identified significant deficiencies in CSS practice including inadequate information collection, excessive assessment delays, premature case closure, failure to recognize cumulative harm, weak safety planning, and poor internal communication. Common clinical issues included unsafe infant sleeping environments (co-sleeping, unsafe bedding), inadequate parental engagement with health services, family violence, substance abuse, and parental mental health issues. Coroner emphasizes system-level failures: workforce shortages, inadequate supervision, and insufficient resources. Recommends CSS focus on timely risk assessment, proper safety planning, cumulative harm assessment, and sustained family engagement. Positive reforms underway through Strong Families Safe Kids initiative including new Advice and Referral Line and Intensive Family Engagement Services.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricspsychiatrygeneral practice

Error types

diagnosticcommunicationsystemdelay

Drugs involved

alcoholcannabismethamphetaminemorphinebenzodiazepines

Clinical conditions

sudden unexpected death in infancy (sudi)bronchopneumoniaacute pneumoniaunsafe sleeping environmentdrowningblunt force traumahypoglycaemiahypothermiajaundicefamily and domestic violenceparental substance use disorderparental mental health disorder (bipolar disorder)parental cognitive impairment

Contributing factors

  • unsafe infant sleeping environments (co-sleeping with adults)
  • inadequate Child Safety Services risk assessment
  • delay in CSS response and case allocation
  • premature closure of CSS notifications
  • failure to recognize cumulative harm
  • inadequate safety planning
  • parental substance abuse (alcohol, methamphetamine, cannabis)
  • family and domestic violence
  • parental mental health issues
  • inadequate parental engagement with health services
  • insufficient CSS workforce and resources
  • poor communication within and between agencies
  • inadequate supervision of junior CSS staff

Coroner's recommendations

  1. Policy and procedure enabling real-time assessment of risk for existing cases to identify high-risk cases during high demand periods
  2. Accessible procedure requiring CSS managers to notify CYS Executive timely about workload demands restricting compliance with policy
  3. Statewide system for ongoing auditing of compliance with policy and procedural requirements with annual public reports
  4. SERT reports include consideration of workplace climate, culture, supervision, management and leadership contributions to practice standards
  5. Comprehensive workforce analysis and finalize Workforce Development Strategy in consultation with stakeholders
  6. Comprehensive Workforce Training and Professional Development Plan
  7. Meta-analysis of SERT issues and learnings conducted regularly and made accessible to all CYS/CSS staff
  8. Robust evaluation of efficacy of CYS/CSS and joint training programs conducted regularly
  9. Finalize and publicly release Monitoring and Evaluation Framework concerning Strong Families Safe Kids reforms
  10. Surveys of client experiences of CSS services included in Monitoring and Evaluation Framework
  11. Effectiveness of Advice and Referral Line and initial assessments of risk and well-being included in Monitoring and Evaluation Framework
  12. Department to consider COPMM recommendations including provision of safe infant sleeping aids, strengthening visiting child health nurse services, prioritizing protective action on family disengagement, and establishing independent review body for infant and child deaths
Full text
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