Authorities aware of concerns about mother's drug use in months before baby died, coroner finds
Warning: The following story contains content which may distress.
In June 2019, the eight-month-old boy was left in a cot and not checked again for about 21 hours while his mother and her partner were doing drugs for three days.
The baby had received 'no or minimal' food or fluid during that time.
His cause of death was severe acute dehydration and acute malnutrition.
A forensic paediatric review said the hour before his death 'would have been extremely distressing physically and emotionally'.
The baby's mother and her former partner were originally charged with murder but have since pleaded guilty to his manslaughter.
As part of a coronial investigation, Coroner Ainslie Kirkegaard examined the 'adequacy' of the Department of Child Safety's response to known concerns about the mother's ability to care for the baby in the lead up to his death.
In February 2019, authorities received two separate notifications about concerns over her ability to meet the child's medical needs.
The baby was assessed as being "at risk of neglect due to inadequate basic care and emotional harm," the findings said.
The next month, authorities received more information about concerns for the baby.
Those included the mother's drug-taking, mental health, history of domestic and family violence and financial poverty.
In early April, Child Safety launched an Investigation and Assessment (I&A) which ultimately found the child was "in need of protection".
The coronial findings said there was a delay of about six weeks between the notification in February and the I&A in April.
The baby was highly vulnerable due to his age and lack of visibility in the community, "so an urgent departmental response was required," the findings said.
Then, between mid-April and May, there was a "lapse in departmental action" because the allocated child safety officer took leave.
The case wasn't reallocated because that officer had already started the process, sighted the child, and assessed there were "no immediate harm indicators".
'While the [baby's] teenage aunt and [neighbours] observed the consequences of [the mother's] increasing drug use on her ability to care for her children, this information was not available to [authorities],' Coroner Kirkegaard said.
"Delay commencing the I&A and a lapse during this phase due to the child safety officer's emergent leave without the case being reallocated, meant plans for [the mother] to undergo urine drug screening were not implemented.
Around May, the baby's aunt — who was 17-years-old — began spending more time at the family's unit to make sure the child was taken care of.
She bought food for the baby and got up during the night to attend to him.
Child safety officers visited the mother at home in late May and discussed an Intervention with Parental Agreement (IPA) — where the department works with a parent to meet the child's needs — which the mother agreed to a few days later.
An internal department review team found the decision to leave the child in her care and start an IPA was "appropriate", given "the absence of any immediate harm indicators" and the mother being assessed as willing and able to work with authorities.
"That said, there was some concern about her ability to engage on a medium to long-term basis given her history of avoiding or disengaging with services," the coroner's findings said.
That findings said there were "missed opportunities" for child safety officers to "record observations" of the boy's physical appearance, speak with the mother about his eating routine and "sight" formula.
Child safety officers involved with the family did not observe any signs of substance use by the mother during their engagement with her over April to June, the findings said.
Coroner Kirkegaard said they also did not identify the emerging pattern of her disengagement with them after 31 May as indicative of her drug use.
On June 3 — just weeks before the baby's death — child safety officers completed an assessment of the mother's strengths and needs.
That assessment identified "drug use, domestic violence and mental health as priority areas of concern at that time".
On June 7, officers visited the family's home, but a man answered the door saying the mother was not well, and the child was not sighted.
Six days later, officers tried to contact the mother to organise a home visit, but she did not answer the call.
The Child Death Review Panel looked at the case and said that six-day delay was "inadequate".
Officers went back to the home on June 17 for an announced home visit.
"It transpires that [the mother] had tried to cancel the visit that morning but when the child safety officer insisted the visit needed to go ahead, [she] said she was at her neighbour's unit and asked that the visit take place there," the findings said.
"She said her neighbour was supporting her with the [baby].
"In truth, there were dog faeces in [the] unit which she did not want child safety officers to see."
The findings said it was during that visit when the mother agreed to drug screening.
The child safety officers who visited the family that day also told the internal departmental review team that the child "did not appear malnourished to them".
According to the findings, the Child Death Review Panel considered the mother's "non-engagement throughout the IPA should have been considered more thoroughly and triggered more intrusive intervention".
The baby died on June 21.
Coroner Kirkegaard found his cause of death was severe acute dehydration and acute malnutrition.
She said the baby's "utterly tragic death" illustrated the "ongoing challenge for child safety and other agencies supporting families where parents have problematic substance use".
She said it was "vital" for frontline officers to be equipped with adequate training and support to identify substance use and understand the risk of harm to children and infants.
Coroner Kirkegaard also added she strongly encouraged the current Commission of Inquiry into Queensland's child safety system "to closely examine Child Safety's resourcing to provide early assertive intervention for families like that of this vulnerable infant".
She closed the investigation.
Her findings did not detail why an inquest would not be held into the baby's death.
The Department of Justice has been contacted for comment.
Asked about the non-inquest findings, a spokeswoman for the Department of Child Safety said the Child Protection Act prevented them from talking about individual cases, 'however when there are failing and weaknesses, we will not shy away from making changes'.
She said, since 2019, the department has strengthened its responses to vulnerable infants, including by updating its practice guidelines regarding high-risk infants. It has also established an alcohol and other drugs' state-wide practice leader to assist with how risks are assessed when parents or children are using alcohol or drugs.
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