Finding into death of Baby S
Deceased
Baby S
Demographics
1y, male
Date of death
2013-05-15
Finding date
2020-11-20
Cause of death
head injury
AI-generated summary
Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and presented with concerning bruises shortly before death. Despite extensive child protection involvement prior to birth and ongoing concerns about maternal drug abuse, family violence, and the unassessed partner, critical gaps in information sharing between services, inadequate risk assessment of the partner, delayed court intervention, and failure to escalate protective actions contributed to missed opportunities for prevention. Key failures included Child Protection's lack of engagement with health services, failure to identify and assess the risk posed by Mr B, inadequate drug screening monitoring, and insufficient frequency of home visits given high-risk infant status.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- deliberate infliction of head injury by de facto partner (Mr B) while biological mother absent
- failure of Child Protection to identify and assess risk posed by Mr B
- inadequate information sharing between Child Protection and health services
- failure to obtain partner's identity and conduct criminal history check
- inadequate drug screening and monitoring of mother
- delayed protective court application
- insufficient frequency of home visits for high-risk infant
- lack of engagement with maternal health services and GP
- lack of communication between childcare centre and Child Protection regarding observed injuries
- early discharge of mother from residential drug treatment against medical advice
- maternal ongoing drug abuse including heroin
Coroner's recommendations
- The Secretary of the Department of Health and Human Services conduct a review and audit of the updated Child Protection policies and procedures for high-risk infants (paragraphs 86-89) to determine whether these changes have effectively improved Child Protection's response to and management of high-risk infants, to be completed no later than 30 June 2021.
- The Secretary of the Department of Health and Human Services conduct a compliance audit to ensure that Child Protection staff are complying with the policies and procedures listed in paragraphs 86 and 89, to be completed no later than 30 June 2021.
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