Inquest into the death of Riley Christopher Shortland

Case Number: 2017/00335331

Date of Findings: 21 October 2022

Magistrate: Deputy State Coroner, Magistrate Harriet Grahame

Catchwords: CORONIAL LAW – Respite care; Voluntary out of home care (VOOHC); Statutory out of home care (SOOHC); Special Care Placement; Behavioural Support Plan; supported out-of-home care; cl. 32 of the Children and Young Persons (Care and Protection Regulation) 2012; ‘special care placement’; safety restraints; transport death

Responses

Recommendations

To the Office of the Children's Guardian:

1. Require Require organisations providing what is now known as specialised substitute residential care (SSRC) and substitute residential care (SRC) to have a transport policy. It is recommended that the Children’s Guardian consider such policies require an assessment of each client’s transport needs and the requirement for the transportation of children and young people assessed as requiring 1:1 support or who have behaviours of concern during the transportation process to be with a driver plus a dedicated carer for the child.
2. Engage with the Department of Communities and Justice to devise an appropriate checks and balance assessment sheet for potential providers of special care pursuant to cl. 27 of the Children and Young Persons (Care and Protection) Regulation 2022 (formerly cl. 32 of the Care Regulation).

To the Department of Communities and Justice:

1. Devise a checks and balance assessment sheet for potential providers of special care pursuant to cl. 27 of the Children and Young Persons (Care and Protection) Regulation 2022 (formerly cl. 32 of the Care Regulation), to ensure that the individual needs of the recipient of the Special Care can be met by the persons providing the care.
2. Devise a policy or procedure setting out the minimum paperwork to travel with a child or young person the subject of a special care Response awaited placement, noting that such providers are not designated agencies and do not have access to ChildStory.
3. Make enquiries with Mobility and Accessibility for Children in Australia Ltd. (MACA) for the purpose of, subject to funding limitations, exploring whether MACA can assist in the formulation of transport related policies and learnings (the “Safe Travels” learnings), particularly within the focus of safety harnesses for children and young people with Autism Spectrum Disorder.
4. Consider making available to organisations delivering SSRC or organisations and individuals supporting children and young persons with Autism, the ‘Safe Travels’ learnings, following a successful trial and roll out to DCJ staff and designated agencies.

To the SNAP Program:

1. Review and amend, or draft a staffing policy addressing hours an employee may work. It is recommended that the policy prevent any employee being rostered on for a period Response awaited in excess of a double shift (representing two 8 hour shifts, or in the alternative, a sleep over shift (where the sleep over shift is not more than 4hrs + 8hrs sleep + 4hrs) plus a further 8 hour shift, without a 10 hour break between the double shift and the next shift, or recommended by an expert in the area. It is understood that such a review would take into account the particular circumstances of staffing levels at camps and allow for exceptional circumstances.
2. To support a comprehensive understanding of any relevant regulations and the above developed staff rostering policy, it is recommended SNAP seek the support of an independent third-party advisor to:
   a. Deliver a session to the senior executive to understand broader risk implications in relation to staffing levels and related policies, legislative and regulatory requirements;
   b. Assess the appropriateness of the policy drafted in response to recommendation (1); and
   c. Deliver a workshop to staff and management to understand the risks around the associated policies and the failure to adhere to them.
3. Develop a policy to ad dress a process for staff to elevate concerns as to staffing challenges, with such process to be independent of executives and managers.
4. Ensure that training in the character of PART, or similar training, becomes a part of a cyclic refresher training program delivered by SNAP to staff and to new employees as soon as practicable after completing their probation period.
5. Update its transport policy to include the following:
   a. The transport driver should be provided with the details of an available contact person (hereafter referred to as ‘support person’) who can attend on the vehicle during that period of transport.
   b. Save for emergencies, a driver transporting a child or young person alone should not exit the vehicle whilst on a motorway, highway, or major public transport corridor. Where there is a need to pull over, such as where a child or young person is presenting a risk to the safe driving, to other persons in the vehicle or themselves, emergency services or a support person should be contacted to assist in the safe access of the child /young person.
   c. Save for emergencies, whilst on a motorway, highway, or major public transport corridor, a driver transporting a child or young person alone should not open the vehicle’s door to access to the child or young person.
   d. Where there is a need to pull over and obtain access to the child in the vehicle, such as where a child or young person is presenting a risk to the safe driving, or a risk to other persons in the vehicle or themselves, emergency services or a support person should be contacted to assist in providing safe access the child or young person .