Finding into death of Child C
Deceased
Child C
Demographics
2y, unknown
Date of death
2020-08-27
Finding date
2022-09-16
Cause of death
Drowning
AI-generated summary
Child C, a 2-year-old living on a rural property in Victoria, drowned in an unsupervised dam. Child Protection had received six reports over 2.5 years documenting neglect, poor supervision, and cumulative harm, but closed the first five at intake stage despite concerning patterns. The coroner found the death was clearly preventable, primarily due to lack of parental supervision. Critical failures included Child Protection's failure to adequately assess cumulative risk, escalate to investigation earlier, and ensure effective follow-up with community services. The case highlights systemic issues in coordinating between Child Protection and ChildFIRST, insufficient assessment of environmental risks (unfenced dam), and inadequate escalation despite multiple warning signs. Earlier protective investigation and intervention could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Lack of parental supervision
- Unfenced dam on family property
- Failure of Child Protection to adequately assess cumulative harm and risk
- Failure to escalate case to investigation phase earlier
- Poor coordination and information sharing between Child Protection and ChildFIRST
- Unsuccessful follow-up of referrals to community services
- Inadequate assessment of environmental safety risks
- Pattern of parental neglect and disengagement with support services
Coroner's recommendations
- Monitor and assess effectiveness of SAFER Children Framework implementation
- Monitor implementation of changes to risk assessment practice and infant practice guidance
- Continue development of operational data reports for ChildFIRST/The Orange Door to track engagement effectiveness and re-reports
- Ensure cumulative harm reviews are conducted consistently following pattern of reports
- Strengthen practitioner response to infants in context of multiple family reports with neglect and cumulative harm
- Improve information sharing and coordination between Child Protection and community services
- Ensure adequate follow-up of unsuccessful referrals to family services
Full text
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