Inquest into the death of Jacob

Case Number: 2018/310524

Date of Findings: 8 August 2025

Magistrate: Deputy State Coroner, Erin Kennedy

CORONIAL LAW – Child abuse, unexplained death of an infant, methylamphetamine, failure to protect child from harm, presentation to hospital with unexplained injury, frenulum injury, gingival mucosa, multiple fractures, multiple unexplained injuries, premature birth, subarachnoid haemorrhage, subconjunctival haemorrhage, Child Protection Unit, traumatic brain injury, suffocation, impact injury, failure to maintain care within DCJ, Joint Child Protection Response Program (JCPRP), case management of infant.

Responses

Recommendations 

To the Secretary of the Department of Communities and Justice

1. The findings are to be provided to the Secretary, and the Minister for Families and Communities, for consideration and review to have the opportunity to carefully consider these findings, Jacob and what occurred in the child protection response.
2. The Secretary consider updating relevant guidance and policies in line with its position with a direction that cases in which an infant has presented with injuries not reasonably accounted for by caregivers, DCJ should retain case management responsibility for the child.
3. The Secretary consider these findings with respect to sufficiency of the procedures around Case Transfers and Sibling Case Coordination, noting Ms Brunner's evidence that a review of the Case Transfer Mandate has been completed and changes made and a review of the Sibling Case Coordination mandate was expected to be completed in 2024.
4. The Secretary give consideration in respect to the training provided to casework teams from caseworker level to Manager Client Services level regarding the assessment of the seriousness of bruising in infants that is not reasonably accounted for by caregivers. This extends to examining how there can be greater inclusion of child protection clinicians in Group Supervision sessions and casework discussions, especially in cases of infants. Consideration should also be given to possibly using Jacob's case as part of scenario-based training of caseworkers.

To the Commissioner of NSW Police Force

1. The Commissioner of Police, NSW Police Force, allocate the police investigation into Jacob's death to the NSW Police Force's Unsolved Homicide Team, Homicide Squad, for review and futher investigation.

To the Attorney General of NSW

1. That the findings are provided to the Attorney General for his consideration and if considered appropriate to do so, with the assistance of the NSW Law Reform Commission, review the sufficiency of criminal offences in NSW with respect to unlawful injury and death of infants and children. This would include consideration generally of whether there would be any benefit to the introduction of an offence in NSW in similar terms to that of section 5 Domestic Violence, Crime and Victims Act 2004 (UK).