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Coronial Inquiry and the Lessons to be Learned

by PeakCare Qld on 2nd July 2014

Home -> Articles -> 2014 -> July -> Coronial Inquiry and the Lessons to be Learned

The report of a Coronial inquiry into the death of a child, 8 year old Faith, who was known to the Queensland child protection system was released earlier this week. Consistent with the Coroners Act 2003 (Qld), the report is available from the Officer of the State Coroner’s website.

Each child death is unique and it is heartbreaking. The Coroner is responsible for examining what happened to inform the family and the public “with a view to reducing the likelihood of similar deaths”. The purpose is not to ascribe or apportion guilt for what happened to that child – other legal and review processes are in place to investigate and consider accountability for the actions or inactions of those involved. Each child’s and family’s circumstances are likely described as disadvantaged, vulnerable, complex and/ or entrenched, impacting on the number and range of services and professionals potentially involved in helping the family and protecting the child. The messages from the findings, conclusions and recommendations of child death case reviews and inquests are best used to inform planning, implementation and review of system changes - legislation and policy; funding and contractual arrangements; program and service system design; staff recruitment, selection, training and supervision to name a few.

The Coroner’s report contains many messages for the statutory child protection agency, other government departments, mandatory reporters, non-government service providers, community members and others. Having found that Faith “slipped through the cracks”, the Coroner made a number of recommendations including about Department of Communities, Child Safety and Disability Services’ intake procedures, information sharing across agencies, feedback loops to reporters, and contractual arrangements with funded intensive family support services.

It is timely to reflect on the messages as responses to many of the recommendations from the Carmody Inquiry are being or have been developed and are being rolled-out. The following are just some of the messages from the report for the child protection system and intersecting services and systems that overlap with the reform agenda:

Listen to children and young people. Faith told adults about what was happening at home. Children’s participation in assessment, decision making, case planning and review should be encouraged, supported and respected and family members, professionals and others who are confided in should be competent to respond to such disclosures.

The onus to be persistent and assertive in engaging hard to reach, resistant, hostile parents/carers/adults and children lies with professionals, not with a child or their parents. In order for this to happen, professionals need the support of co-workers, their supervisor, management and the organisation, training, professional development and regular supervision.

Mandatory reporters and others who suspect or are aware of harm to a child need to know how to respond and what to do with the information if children and their families are to get the help they need, when they need it. This has implications, for example, for community education messages, community based intake and referral processes, making reports to the statutory agency, service system design and capacity at local area level, and information sharing provisions.

Professionals working with vulnerable and at risk children and families need to be able to share relevant information about a child and family’s circumstances across services and sectors. Planning and delivering the right response at the right time are underscored by professionals’ understanding the who, what and when about sharing information about a child’s and family’s circumstances. Responsible and timely information sharing will inform approaches to family members, comprehensive assessment and planned interventions.

Collaborative working arrangements across services and sectors are vital to joining up what’s known about a family and the development and implementation of effective responses. Families, like Faith’s family, are likely to be adversely affected by domestic and family violence, substance abuse, housing instability or homelessness, mental health issues and / or poverty. This has implications for legislative changes, local area planning, strengths based approaches to working with families, community based intake and referral, and having a lead case manager.

The above touches on only some of the issues raised in the Coroner’s report about Faith’s death. We must strive to make good use of the messages from this review and other case reviews as well as research when we engage in co-design, collaborative planning, breaking down the silos, reviewing progress, and when working with children and their families.

Tracey Smith

Principal Policy Adviser

PeakCare Queensland