Finding into death of Rory

Contributing factors

• Inadequate storage of schedule 8 medication accessible to child
• Parental opioid and benzodiazepine dependence limiting supervision capacity
• Chronic drug abuse by both parents rendering them incapacitated
• Absence of effective monitoring of prescription medication use
• Premature closure of child protection involvement
• Failure to implement protection orders despite high-risk indicators
• Inadequate inter-agency communication and case allocation failures
• Lack of mandatory drug rehabilitation participation by parents
• Absence of specialist pain management or mental health intervention

Coroner's recommendations

1. Where a case has not been investigated or significant risk identified, and the family leaves without notifying DHS, the file should remain open with periodic reviews and active efforts to locate the family rather than waiting for further notification
2. Information regarding children whose whereabouts are unknown should be maintained by DHS and made accessible to high-ranking police and school principals
3. DHS should ensure statewide practice whereby a designated worker oversees and liaises monthly with external organisations engaged to provide assistance to DHS clients
4. DHS workers should receive education focused on identifying drug and alcohol dependency and strategies for managing people presenting with these effects
5. The Australian Medical Association should make mandatory continuing education for prescribers of addictive medication, including training on identifying drug dependency, abuse prevention strategies, and alternative therapies to address underlying issues
6. The Department of Health should regularly audit records to identify medical practitioners prescribing schedule 8 drugs at disproportionately high rates compared to peers and investigate the reasons