Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk, uncontrollable defecation/urination, extreme pain, delirium and fever, her foster carers failed to seek medical attention. The Department of Families and Children Services (FACS) breached statutory obligations to monitor her welfare, conduct regular home visits, conduct three-monthly case reviews, and properly re-register the foster carer. Multiple systemic failures—inadequate staffing, poor information systems, failure to recognise cumulative harm, and assumption that kinship carers needed less oversight—created an environment where these breaches went undetected. The death was completely preventable with early antibiotic treatment.