Child safety officers in Tasmania had a lack of understanding about sudden infant death syndrome, according to the Coroner, who has found that the system failed to protect children in its care.
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A coronial inquest into the deaths of six babies and one child between 2014 and 2018, whose families were all known to Child Safety Services (CSS), has found the system had been notified of the risks to the childrens safety, but failed to take steps to mitigate those risks.
It has led Coroner Olivia McTaggart to urge the state government to continue reforms within child protection.
She said reforms would address the "multiplicity of issues" raised in the inquest, and may "result in the decrease in risk to vulnerable infants and children".
The inquest examined the deaths of a baby who drowned in the bath, three who died from sudden infant death syndrome while co-sleeping, and one female child and her baby son who both died in a car crash.
[There was] insufficient appreciation by CSS practitioners regarding the risk of infant death caused by caused by unsafe sleeping environments.
- Tasmanian Coroner Olivia McTaggart
While Coroner McTaggart found that CSS did not cause any of the deaths she noted that there was a fine line in making this decision, especially in relation to the deaths of the mother and particularly her baby.
She said the decision making processes of CSS were flawed, and failed to follow procedure or good practice.
"As a result, there were lost opportunities to protect the vulnerable infants which, if they had been taken, may have resulted in different outcomes," she said.
Issues highlighted within CSS included inadequate data collection in relation to risk assessments of children, lengthy delays in assessments, a lack of attention to cumulative harm and poor internal communications.
Coroner McTaggart said cases were often closed too early, and that there was "insufficient appreciation by CSS practitioners regarding the risk of infant death caused by caused by unsafe sleeping environments."
The coroner noted that the deaths of the children occurred during a period of very high demand for Child Safety Services, in a department that was underfunded and not adequately staffed. But she added that change had occurred with the Safe Families Safe Kids reforms, and that an adoption of a public health approach on these matters were positive.
This reform by the government included a $51 million redesign of the system, a 20 per cent increase of front-line staffing since 2014, and introduction of the Advice and Referral Line (ARL).
"I have dealt in this finding with some issues emerging as a result of the reforms. These include the need to ensure that the ARL operates as intended, that IFES is effective, and that concepts of risk are made consistently clear across many services," Coroner McTaggart said.
She also gave weight to a submission by the Council of Obstetric and Pediatric Morbidity, suggesting that drug and alcohol services in regional Tasmania be improved, and Tasmanian Child and Family Centres be utilised more for at-risk families.
Also, that portable sleeping infant pods and increased family nursing visits should be given to at risk families, and that an independent body should always conduct reviews into the deaths of children known to CSS.
A government spokesperson said continued improvements were being made to the system, and noted the implementation of the ARL to provide earlier support to families before crisis.
"While the Coroner doesn't attribute these deaths to the CSS and speaks positively about the reforms to the child safety system, we will continue a program of continuous improvement in child safety practice.
"We are now seeing more support for families at risk, fewer cases referred for statutory child safety intervention and a decrease in the rate of children and young people entering out-of-home care."