Seventeen findings were made in the coronial inquest into the circumstances surrounding the death of a boy drowned by his mother in the Murray River at Moama.
Coroner Theresa O’Sullivan made recommendations for the NSW and Victorian Police Commissioners, the Department of Communities and Justice, Murrumbidgee Local Health District, the Catholic Education Office, and the Emergency Services Telecommunications Authority which takes 000 calls.
They included that the NSW Police Commissioner review the domestic violence standard operating procedures and associated training to ensure that the significance of listing children as “persons in need of protection” were well understood.
The commissioner was also asked to ensure greater emphasis on “critical analysis” of report made to NSW Police for concerns of welfare relating to missing persons reports included making prompt and suitable inquiries that included consideration of any personal knowledge of the people involved, information provided by the person reporting and their criminal history.
Police are also to give consideration to risk factors including mental health, use of drugs or alcohol, care and protection orders, and any significant family conflict; as well as documenting a risk assessment when a child is taken from their home without the consent of their usual carer, when making missing persons reports.
Among the directions from Ms O’Sullivan to the Victorian Police Commissioner was the need for a “cautious” approach when police were called to conduct a welfare check on vulnerable people, such as children, and associated policy and training for this.
The Department of Justice and Communities was directed to receive training about the significance of whether orders in relation to care and custody are in place in the event children are removed from their usual carer, the significance of whether an apprehended domestic violence order naming children as persons in need of protection is in place if the children are removed from their usual carer, and the importance of assessing the risk that a child may be removed from their carer when information suggests a possibility of that is received by the department.
The coroner also recommended the department officers receive training about steps that can be taken if a child is taken from their home, including telling police; knowing what information is of particular relevance in 000 calls; assessing risk and the appropriate information that should be accessed, including from other agencies.
WHen it comes to Murrumbidgee Local Health District (MLHD), the coroner recommended it prepare a written protocol about the transfer of information between Corrective Services NSW and MLHD in relation to people released from custody.
Ms O’Sullivan also instructed MLHD to review its policies to ensure emphasis on the need for practitioners to obtain collaborative background information about its consumers.
The Catholic Education Office was recommended to review its child protection policy to ensure that when any mandatory reports were made to the Department of Communities and Justice about a child that they also call 000 and make a report to police.