A coroner has warned the tragic death of a two-year-old boy who endured “significant pain and neglect” in his short life could happen again today. Picture: NCA NewsWire/Simon Bullard.
A coroner has warned the tragic death of a two-year-old boy who endured “significant pain and neglect” in his short life could happen again today. Picture: NCA NewsWire/Simon Bullard.

Frightening warning over boy’s death

A coroner has issued a blunt warning about the state of child protection services in New South Wales, saying the tragic 2012 death of a young child could happen again today.

The boy endured "significant pain and neglect" in his short life and was failed by the community, deputy state coroner Harriet Grahame said on Wednesday.

And despite changes within the child protection department, Ms Grahame says she believes children will continue to "fall through the cracks".

"The tragedy remains that children such as (the boy) will continue to die in pain unless further resources are allocated to the child protection department in NSW," she said.

The boy, who can only be identified as Z, was two years, seven months and six days old when he died from a traumatic head injury at Wollongong Hospital on August 3, 2012.

Child protection authorities knew he was at risk but failed to adequately act.

The Department of Communities and Justice "frankly conceded" staff should have held a face-to-face meeting with the boy and his mother, Ms Grahame said.

Yet eight years on, deputy secretary Simone Czech could not say for sure if Z would be seen by caseworkers today.

She was only able to tell the court it was "likely", Ms Grahame said.

"Z deserved a better life than he had," Ms Grahame told a near-empty courtroom on Wednesday morning.

"I acknowledge his pain and feel great sorrow that we failed to keep him safe."

No one has ever been convicted of inflicting the injuries that led to Z's death.

His mother was sentenced to 4.5 years in prison in June 2015 for failing to seek medical help for him, but there was no suggestion she caused his injuries, or was there when he was hurt.

The inquest was delayed during the mother's court proceedings, and again when the coronavirus pandemic hit.

Ms Grahame said despite the passage of time and substantial changes within what is now known as the Department of Communities and Justice (DCJ), she was "significantly concerned" the issues surrounding Z's death had not been addressed.

"This kind of tragedy could still happen today," she said.

The magistrate was particularly alarmed to learn DCJ does not provide a statutory response to about 70 per cent of children who are subject to a risk of serious harm (ROSH) report.

Ms Czech had told the inquest the demand for child protection "outstrips our capacity to respond", the magistrate said.

She said there was an urgent need for better resourcing, adding it was clear Z's family needed wraparound preventive support well before his death.

"These issues must be acknowledged at the highest level," she said.

Magistrate Grahame recommended the DCJ abolish handwritten forms in situations where caseworkers are responding to ROSH reports, and ensure ROSH reports are allocated and assessed within 24 hours, and escalated if they cannot be.

She recommended Z's death be referred to the unsolved homicide unit, and that NSW Police establish a reward for information leading to the arrest and conviction of a person over his death.

Originally published as Frightening warning over boy's death


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