Finding into death of Lachlan John Howe

Contributing factors

• family violence perpetrated by father including emotional abuse, controlling behaviour and abusive communications
• delayed and incomplete mental health referrals to NECAMHS
• failure to engage Lachlan with mental health services prior to death
• lack of coordination between school, paediatrician, Child Protection and mental health services
• failure to escalate suicidal ideation to Child Protection despite service involvement
• inadequate consideration of family violence as a contributing factor to mental health presentation
• inadequate investigation by Child Protection despite 15 previous notifications
• failure to recognize cumulative harm
• misidentification of Lachlan's Aboriginal status by Child Protection
• parent's limited capacity to engage support due to family violence victimization
• adolescent's refusal to engage with support services and family

Coroner's recommendations

1. Child Protection should improve investigation protocols at intake phase, particularly where there is significant prior history, by gathering information from professional sources and service agencies as mandated by Child Protection Manual
2. Child Protection should consider cumulative harm in assessments of family notifications using the Best Interests Case Practice Model, with critical reflection on historical reports
3. Child Protection should ensure Aboriginal and Torres Strait Islander children are identified correctly and provided with culturally sensitive services
4. Child Protection should recognize and support mothers as family violence victims whose capacity may be diminished, exploring additional support options prior to case closure
5. Medical practitioners, particularly paediatricians, should access and maintain knowledge of RACP guidance on mental health services and child protection responsibilities
6. Paediatricians and medical practitioners should consider consulting with Child Protection or ChildFIRST when patients refuse mental health support despite identified risk factors
7. Schools should consider making notifications to Child Protection when students demonstrate escalating suicidal ideation with unwillingness to engage support services
8. Schools should assess and address the impact of family violence on students' mental health and treat mental health concerns within the context of trauma exposure rather than in isolation
9. Schools should implement and resource family violence response protocols through MARAM framework
10. Mental health referral processes should include systematic follow-up protocols to ensure referrals are received and engagement is established, with escalation procedures when contact with families is unsuccessful
11. Mental health services should establish clear procedures for urgent follow-up when individuals with active suicidal ideation disengage
12. Education systems should implement the mental health practitioner initiative in secondary schools to provide professional assessment and escalation capacity
13. Education systems should provide regular training to school staff on identifying and responding to family violence among students and on suicide risk assessment and intervention
14. Implement the MARAM framework in schools to build consistent understanding and response to family violence
15. Government and schools should support the mental health reforms recommended by the Royal Commission into Victoria's Mental Health System, particularly Recommendation 17 regarding evidence-informed initiatives and digital platforms for mental health support