Inquest into the Death of Child LDW (Name Subject to Suppression Order)

Contributing factors

• unsecured prescription opioid medication left accessible to child
• lack of supervision of unwell child sleeping 12+ hours without checking
• carer struggling with depression, wrist injury, and inadequate support
• carer's use of illicit drugs while caring for children
• poor school and daycare attendance not escalated
• inadequate case management supervision of carer
• geographic distance between case management office and placement
• failure to act on concerns raised by mother and grandmother
• inadequate standard of care assessment despite allegations of carer's drug use
• delayed annual care review
• new and undertrained case manager without adequate oversight

Coroner's recommendations

1. Department should improve coordination between district offices to ensure practical on-ground support when geographic distance is a barrier
2. Schools should be more proactively engaged when children have poor attendance; non-attendance should be treated as a potential indicator of neglect
3. Daycare attendance should be monitored more closely with direct follow-up of absences rather than relying on carer reports
4. Standard of care assessments should be initiated promptly when concerns are raised about carers, with timeframes for investigation
5. Case managers should conduct thorough home inspections including all rooms, not just visible areas
6. Educational conversations with carers about medication and poison safety should be prioritized, with emphasis on prevalence of accidental child poisoning
7. New case managers should complete core training before being allocated cases and should have formalised mentoring arrangements
8. Carers should be assessed for capacity to cope, especially when personal circumstances change (e.g., wrist injury, depression, relocation stress)
9. Annual care reviews should be completed on schedule and include assessment that accommodation meets safe storage requirements
10. Concerns from multiple sources (mother, grandmother, school) should trigger escalated action within appropriate timeframes
11. Reunification planning should not overshadow active monitoring and protection of children currently in placement