Inquest into the Death of KLD (Subject to Suppression Order)

Contributing factors

• Progressive physical and psychological trauma over preceding months
• Fall from couch resulting in catastrophic brain swelling
• Systems-taxed by prior injuries and illness
• Lack of dedicated case manager following transfer to Kalgoorlie
• Contact visit feedback reports not reviewed by case worker
• Decline in child's demeanor not identified or investigated
• Foster mother's advanced pregnancy affecting supervision
• No baseline paediatric assessment on relocation
• Failure to recognise child was no longer developing normally
• Delayed recognition and intervention for child abuse/neglect in care setting

Coroner's recommendations

1. On transfer of children in care from one location and set of carers to another, there be appropriate assessment by consultant paediatricians in the new location to record a child's welfare and progress, in addition to annual assessments
2. All children transferred from one location to another have a case worker; only successful long-term foster placements should be placed on a monitored list after a suitable period of reasonable review
3. All contact of DCP workers with children in care be recorded and appropriately assessed in a group meeting to ensure adequate supervision of the care and treatment provided to children in departmental care
4. Resourcing for the State Mortuary to be provided with a CT scanner to assist forensic pathologists with investigations and enable better compatibility between pathologists and clinicians