Coroner's Court of Western Australia

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

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

Delivered on : 4 April 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendation :

I recommend that the Department of Communities consider further updating their Casework Practice Manual section 2.2.4 to include guidance on encouraging a general health assessment to be completed by a general practitioner where a child has a disability or chronic health issue and there is no recent relevant information about the child’s health and there are concerns about neglect.

Orders/Rules : N/A

Suppression Order : Suppression of the deceased’s name, the deceased’s siblings and other family members from publication and any evidence likely to lead to their identification. The deceased is to be referred to as Child LT.

Summary : The deceased was an 11 year old boy with a significant medical history, including Cornelia de Lange syndrome and severe cardiac disease. He had a profound disability and was unable to walk, talk, toilet independently or eat solid foods and he required a high level of supervision and care, similar to that required for a toddler. On 19 August 2021, the body of the deceased was discovered on the floor of his bedroom in an unlocked house by his great aunt. She had gone there to check on him after being advised by the Department of Communities that his mother was in hospital and nobody knew who was caring for the deceased.

For most of his life, the deceased had lived with his mother and extended family. In the last couple of years leading up to his death, the deceased’s mother had separated from her husband and lost custody of her youngest child, and she appears to have descended into a pattern of drug and alcohol addiction. The Department of Communities had become involved with the family but the deceased and his other younger sister remained in their mother’s care despite ongoing concerns about possible drug abuse and neglect.

Heightened concerns were raised in May 2021, particularly by the deceased’s school as it was apparent he had unaddressed dental issues that were causing him pain and various therapy needs that were not being met as the deceased’s mother would not engage with the recommended care plan. Communities opened a child safety investigation at that time.

While the child safety investigation was still ongoing, the deceased’s mother turned up an hour late to collect the deceased from school and seemed dazed and confused and likely affected by substances. Communities were informed and child protection officers went to the deceased’s family home to check on the state of their mother. It was apparent she required medical attention, so she was taken to hospital by ambulance while child protection officers tried to find alternative accommodation for the deceased and his sister. Their father was contacted and he indicated he was unavailable, but he agreed for the children’s maternal great-aunt to take responsibility for them. The two children were entrusted into the care of their great-aunt, who took immediate steps to ensure they were safe and comfortable. She noticed the deceased had severe nappy rash and a sore on his ear, so she tended to these issues, which quickly resolved. The children remained in their great-aunt’s care for a few weeks and in that time the deceased showed an overall improvement in his well-being. However, the great-aunt was unable to care for them long-term and their mother had been discharged from hospital without any finding of illicit drug use or diagnosed mental health concern that might affect her ability to care for them, so the children were returned to her care on Friday, 13 August 2021 with a safety support plan in place.

It was later established that from the time the two children returned to their mother’s care, their mother was abusing alcohol and she has little recollection of the events. She did not access her support network and was obstructive and misleading towards child protection officers when they made contact with her on the Monday, Tuesday and Wednesday of the following week to check on the children. On the Tuesday afternoon, the deceased’s younger sister sent desperate text messages to her great aunt, which were forwarded to her father and child protection officers. The children’s father went to the house that night and found the house in disarray, the deceased crying and the deceased’s mother passed out in bed. He woke the deceased’s mother and told her to care for the deceased, then collected the deceased’s sister and left. He initially planned to return to collect the deceased, but after communicating with the deceased’s mother, he did not return and the deceased was left in his mother’s care.

The deceased’s mother later told police she thought his father had taken him, so she spent the Tuesday night and Wednesday drinking alcohol on her own in the house. When she received a text message on the Wednesday afternoon from Communities informing her the deceased was not with his father, she realised he was still at home. She went to check on him and found he had died in his cot. She moved his body to the floor of his bedroom then went and drank more alcohol before leaving the house in a heavily intoxicated state. She was detained by police and taken by ambulance to hospital, where she was spoken to by police officers and health staff, but she did not disclose what had happened to her son. She was admitted as an involuntary psychiatric patient and Communities were advised by hospital staff of her admission. They began to make enquiries to locate the two children, which eventually led the deceased’s great aunt to find his body on the floor of his bedroom at around 1.00 pm on 19 August 2021.

A Homicide Squad investigation commenced. As part of the investigation, a forensic pathologist attended the scene and then conducted a comprehensive post mortem examination. The forensic pathologist was unable to establish a cause of death, noting the deceased had severe heart disease and epilepsy, which might have caused his sudden death at any time, or alternatively he may have died from an infection, suffocation or malnourishment and dehydration. There was no evidence to establish that any person caused his death and no charges were laid by the police.

The Deputy State Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of his death.

The Deputy State Coroner gave consideration to the supervision provided by Communities prior to the deceased’s death and made one recommendation in relation to a health assessment for vulnerable children with a disability who are the subject of an open investigation.

Catch Words : Department of Communities : Neglect : Child with Disability: Possible Homicide : Open Finding

Last updated: 19-Apr-2024

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