Inquest into the death of CS

Case Number: 2017/69591

Date of Findings: 15 July 2022

Magistrate: Deputy State Coroner, Magistrate Teresa O’Sullivan

Catchwords: CORONIAL LAW – manner of death - death by presumed drowning – consequence of acts of mother – grandmother raised alarm - family known to the Department of Families and Community Services – child protection – mental health services – cross-border policing – NSW Police Force – Victoria Police – Murrumbidgee LHD – ESTA – Catholic Education Office

Responses

Recommendations

To the NSW Commissioner of Police:

1. Consider the addition of the following features to the Apprehended Violence Order application system within COPS:
   a. An alert which identifies to an adjudicating NSWPF officer his or her obligations pursuant to s. 38 of the Crimes (Domestic and Personal Violence) Act 2007 (“CDPV Act”) (including a reference to the potential existence of indirect violence); and
   b. A mandatory field requiring that any reasons as required by s. 38 of the CDPV Act be recorded in writing. 
2. Review of the Domestic Violence Standard Operating Procedures (“DV SOPs”) and associated training to ensure that the significance of listing children as Persons In Need of Protection (“PINOPs”) is well understood; 
3. Give consideration to the extent to which the tragic circumstances of CS’ death, in de-identified form, might form the basis for ‘case studies’ emphasising the significance of listing children as PINOPs, including as regards the availability of police responses; 
4. Ensure greater emphasis on ‘critical analysis’ of reports made to the NSWPF for concerns for welfare relating to missing persons reports including:
   a. Making prompt and suitable inquiries to inform any risk assessment for the purpose of determining whether or not a missing persons report is warranted, including consideration of the following avenues of inquiry;
       i. Personal knowledge of the people involved;
       ii. Information provided by the person reporting;
       iii. Information provided by any other person at the scene or elsewhere;
       iv. Interrogation of the COPS system, including intelligence reports via MobiPol;
       v. Criminal histories; and
       vi. Other environmental factors. 
   b. Ensuring that consideration is given to the following risk factors by officers when assessing whether a missing persons report should be taken:
       i. Mental Health;
       ii. Health (drugs and/or alcohol);
       iii. Care and Protection Orders;
       iv. Domestic Violence related;
       v. Employment/Education issues;
       vi. Significant family conflict/abuse related; and
       vii. Unusual behaviour.
   c. Giving clear guidance as to when the taking of a child from a parent could constitute an abduction, and when there is the need to investigate circumstances, even where orders have not yet been made;
   d. Performing and documenting a risk assessment when a child is removed from their usual residence without the consent of their usual carer, to determine whether a missing persons report should be made;
   e. Utilising procedures to ensure all known information that could be relevant to a risk assessment is accessed for the purpose outlined in (d) above; and
   f. Adopting a ‘cautious’ approach where vulnerable persons (such as children) are involved, and associated policy and training as to this aspect. 
5. Consider the extent to which the tragic circumstances of CS’ death, in de-identified form, might form the basis for ‘case studies’ emphasizing the importance of a cumulative and holistic consideration of information held by agencies.

To the Victorian Chief Commissioner of Police:

1. Give consideration to improving policies and practices so as to ensure clear guidance as to:
   a. The need for active consideration of the missing persons policy when a child is removed from their usual residence without the consent of their usual carer, including the performance and documentation of a risk assessment to determine whether a missing persons report should be made;
   b. Procedures to ensure all known information that could be relevant to a risk assessment is accessed for the purpose of determining whether a missing persons report should be made; and
   c. The need for a ‘cautious’ approach where police are called to conduct a welfare check on vulnerable persons (such as children), and associated policy and training as to this aspect. 
2. Consider the extent to which the tragic circumstances of CS’ death, in de-identified form, might form the basis for ‘case studies’ emphasizing the importance of a cumulative and holistic consideration of information held by agencies.

To Emergency Services and Telecommunications Authority (ESTA):

1. Consider the circumstances of this incident (as appropriately anonymised) as the basis for a training module or case study, highlighting the importance of accurate reference to the content of a Computer Assisted Dispatch (“CAD”) event.

To DCJ:

1. Ensure that DCJ officers and employees receive training as to:
   a. The significance of whether orders in relation to care and custody are in place in the event that a child or children are removed from their usual carer;
   b. The significance of whether an ADVO naming a child or children as a PINOP is in place in the event that a child or children are removed from their usual carer;
   c. The importance of assessing the risk that a child may be removed from their usual carer when information suggesting a possibility of that is received by DCJ.
2. Prepare a simple fact sheet along the lines of that prepared in 2017 in respect of health and education to be used by DCJ employees, and upon which DCJ employees should be trained. 
3. Ensure that DCJ officers receive training in relation to steps that can be taken in the event that a child is removed from their usual place of residence, including:
   a. Appropriate means of communicating that information, and updating information, to police;
   b. What information is of particular relevance for the purpose of 000 calls and other communications with police;
   c. Interstate communication of information;
   d. The need for risk assessment on an ongoing basis in such circumstances, and the appropriate sources of information that should be accessed, including from other agencies;
   e. The need for ongoing communication with police to inform them of any relevant information and any risk assessment;
   f. The range of orders and warrants that are available, and the circumstances in which employees of DCJ should seek or should provide input for the purpose of others seeking those orders or warrants.

To the Murrumbidgee Local Health District (MLHD):

1. Prepare a local written protocol or procedure concerning the transfer of information between Corrective Services NSW (“CSNSW”) and MLHD in relation to persons released from custody; 
2. Provide the Ministry of Health with a copy of the:
   a. Submissions of Counsel Assisting dated 17 September 2021;
   b. Submissions of MLHD dated 29 October 2021; identifying the issues raised by this inquest concerning a potential protocol or procedure for the transfer of information between CSNSW and Local Health Districts in relation to persons released from custody, for consideration of the appropriate officer within the Ministry of Health. 
3.  Review applicable policies and procedures to ensure:
   a. Emphasis upon the need for practitioners to obtain collaborative/corroborative background information regarding consumers;
   b. Relevant sources of such information (for example, general practitioners, family members) are set out. 
4. Introduce a fact sheet regarding the operation of s. 16A, Children and Young Person (Care and Protection) Act 1998 (NSW) (“CYP Act”) and the exchange of information between agencies with responsibility for the safety, welfare or wellbeing or children or young people.

To the Catholic Education Office:

1. Review the policy entitled ‘Child Protection Policy: Managing Risk of Significant Harm and Wellbeing Concerns’ to ensure they stipulate that when a mandatory report is made to the Department of Communities and Justice pursuant to the Children and Young Persons (Care and Protection) Act 1998 (NSW), the reporter must consider making a subsequent report to NSW Police by calling 000.