Inquest into the Death of LCTM

Contributing factors

• father's fetal alcohol spectrum disorder and cognitive impairment
• father's history of violence and substance abuse
• failure to diagnose father's FASD prior to death
• delayed pre-birth planning due to late referral
• Department caseload and workload issues
• incomplete information gathering regarding father's history of violence
• family non-disclosure of domestic violence
• communication failures between Perth-based and Bunbury-based caseworkers
• failure to involve father's Cannington case manager in planning meetings
• failure to appoint a co-worker for father despite request
• lack of supervision of unsupervised parental contact
• failure to document warning sign (rough feeding incident)
• decision not to take baby into care despite high-risk factors

Coroner's recommendations

1. Early pre-birth planning should be prioritised where an unborn baby may be at risk
2. Where early pre-birth planning cannot be undertaken, a cautious approach should be taken to assessing risk
3. Department for Child Protection and Family Support should take a precautionary approach where there is insufficient information about a case and potential for dangerous outcome
4. Department should review methods of maintaining contact with highly vulnerable and transient youth and direct sufficient resources to monitoring location of troubled children
5. Multidisciplinary team at senior level should make decisions about allowing individuals back to hospital wards after Code Black incidents
6. Hospital and Department processes should include documentation of decision-making regarding de-escalation of security incidents
7. Regular 'Babies at Risk' collaborative meetings between Department case workers and hospital social workers/midwives should be maintained