Finding into death of Aaron

Contributing factors

• lack of mental health assessment despite documented self-harm
• failure to establish stable therapeutic relationship with skilled worker
• episodic DHS involvement without sustained engagement
• multiple worker changes without continuity
• inadequate collaboration between DHS and school
• failure to implement promised supports (youth worker, sporting activities)
• inadequate response to suicidal ideation expressed to friends
• lack of cumulative harm understanding across 12-year notification history
• absence of formal protection application despite 14 notifications
• building security allowing access to high-risk areas

Coroner's recommendations

1. Department of Human Services should impose mandatory practice standard requiring unit manager or above to review DHS response to any child protection notification once a child's history accumulates three notifications but has not resulted in response beyond voluntary intervention; unit manager must record explicit rationale for not pursuing formal intervention.
2. DHS child protection practitioners (CPW2/3), team leaders (CPW4), and unit managers (CPW5) working primarily with adolescents must undertake mandatory training at commencement and then every two years to develop and maintain skills in identifying and addressing adolescent mental health issues.
3. Department of Human Services should develop clear and detailed guidelines outlining when child protection practitioners should make referral to specialist mental health professional or service to ensure timely mental health advice and treatment, incorporating these guidelines into all current practice advice in Child Protection Practice Manual relating to adolescence and mental health issues.