Baby Ebony inquest: Families SA criticised by Deputy Coroner over death of infant

FAMILIES SA has been heavily criticised by a coroner for failing to prevent the death of a baby who was “mercilessly and serially brutalised” to death by her drug abusing father.

FAMILIES SA has been heavily criticised by a coroner for failing to prevent the death of a baby who was “mercilessly and serially brutalised” to death by her drug abusing father.

Deputy State Coroner Anthony Schapel on Thursday handed down his findings into the death of baby Ebony, who died on or about November 8, 2011.

Mr Schapel said it was an “egregious oversight” that Families SA did not contact welfare authorities in NSW about the father’s “propensity towards ill treatment of young children”.

He has recommended the establishment of a national database for child protection cases to help prevent further tragedies.

Mr Schapel found Ebony’s death could have been prevented if Families SA and SA Police had conducted more thorough investigations into her father and a broken leg she suffered in his care.

The inquest heard Ebony’s parents had moved to South Australia from NSW, where they were known to welfare authorities.

Baby Ebony, who was born prematurely, died when she was four months old.

Mr Schapel said a nationwide alert should be sent out when one state loses contact with problematic parents.

Ebony, four months, sustained up to 70 injuries when she was fatally bashed by her drug addicted father, who pleaded guilty to criminal neglect and was jailed for nine years.

Her cause of death at autopsy was blunt head trauma with multiple bilateral skull fractures that resulted in haemorrhages.

Ebony’s mother, who also pleaded guilty to criminal neglect, walked from court on a two-year good behaviour bond.

Neither of the parents, who moved from Goulburn, NSW, to Adelaide in mid-2011, can be identified as the mother was a youth at the time of Ebony’s death.

The inquest heard the father’s violent history was not initially passed on to South Australian authorities because a NSW social worker could not find any background on him.

It also heard the father, who admitted smoking marijuana every other day, was told to look up a drug support agency in the White Pages by a Families SA social worker.

The body of Baby Ebony was left in a Brooklyn Park unit for a week before her parents reported her death to authorities.

In his findings, Mr Schapel said:

FAMILIES SA failed to take steps to examine the background of the father or monitor Ebony’s care and protection. The agency should have reopened Ebony’s file but instead abdicated its responsibilities.

A COHESIVE and thorough investigation into the cause and circumstances of Ebony’s thigh injury which took into account the opinions of the radiologists and the father’s background should have been carried out by Child Protection Services, Families SA and SA Police.

AN ERRONEOUS view was formed that Ebony’s parents had effectively been cleared of having caused her thigh injury.

EBONY should have been removed from her parents after the investigation into her thigh injury.

FAMILIES SA did not address the father’s heavy cannabis habit as required under child protection laws.

SA POLICE failed to identify associated events of Ebony’s thigh injury with an alleged domestic violence assault by the father on the mother just weeks later.

Baby Ebony’s casket at her funeral in Goulbourn, NSW. Picture: Supplied

Mr Schapel said he found that Ebony’s fatal injuries had been deliberately inflicted by her father.

Ebony’s death was not reported to authorities until a week later, when they attended the Families SA office at Woodville.

“It is no exaggeration to say that the post-mortem examination revealed that Ebony had been mercilessly and serially brutalised,” he said.

He said information was never sought by Families SA about the violent history of Ebony’s father, which “could have made all the difference”.

“This was an egregious oversight, the incompetence being all the more culpable having regard to the relative ease with which it could have been obtained and the fact that the neglect in failing to obtain the information persisted over several months,” he said.

Baby Ebony died when she was four months old. Source: Facebook.

Mr Schapel said there was an “undue tolerance” to cannabis consumption by child protection authorities.

“There is, I find, a worrying tendency within the child protection environment to regard cannabis consumption as having limited importance and to downplay the dangers associated with the consumption of cannabis within a family setting such as this,” he said.

He said an investigation into Ebony’s thigh injury lacked proper cohesion and slammed Families SA supervisor Loretta Parenta’s “lack of appetite” for the task.

“Any proper investigation into whether an injury such as Ebony’s was deliberately inflicted could not have failed to take into account the propensities and background of the parents,” he said.

“No reasonable person in Ms Parenta’s position as an experienced member of a child protection agency could have failed to understand that.

“It is also surprising that SAPOL, which was a participant in the investigation, would also not have recognised (the father’s) background as an essential element in the investigation.

Women’s and Children's Hospital radiologist Dr Christopher Pozza outside the Coroners Court.

Mr Schapel said a note effectively closing Ebony’s file, which was inserted by Ms Parenta and ended any further participation by Families SA, was “erroneous”.

“The file note stated that the parents had been cleared of causing Ebony’s thigh injury and that because the parents had engaged with health services and that no further concerns had been raised by them, that the case would now be closed,” he said.

“The parents had never actually been cleared of causing the injury to the child in the sense that it had been established that the injury had not been deliberately inflicted.

“At best there was an opinion formed that the cause of injury as described by the parents was mechanically feasible.”

Baby Ebony with her drug abusing father, who bashed her to death.

He said Ms Parenta’s claim that a lack of resources within Families SA was an issue was “easily made, difficult to refute and even more difficult to substantiate.”

In addition to the implementation of a child protection national database, Mr Schapel recommended that drug use within families with children be immediately reported to the Families SA Child Abuse Report Line.

Families SA supervisor Loretta Parenta outside the Coroners Court.

Child Protection Services officer Luke Watkinson outside the Coroners Court.

“I recommend that the Child Protection Services, Families SA and SAPOL recognise that an investigation strategy in respect of an injury to a child comprises more than a bare assessment as to whether the injury is consistent in a mechanical sense with an explanation proffered for that injury,” he said.

“An investigation needs to take into consideration the background and propensities of persons connected with the child and the intrinsic likelihood or otherwise of the explanation having regard to all of the relevant circumstances.

“A person should not be regarded as having been ‘cleared’ of having deliberately caused an injury to a child except in circumstances where the investigators are satisfied with some certainty that the injury was not deliberately caused.”

Mr Schapel said the closing of files should be authorised by an officer superior in rank or position to that of a supervisor.

He said regular formal inter-agency liaison meetings should take place between various service providers and Families SA to discuss families at risk.

Outside court, Ebony’s mother said she was happy with Mr Schapel’s findings but angry that authorities had not told her about her partner’s violent background.

“If Families SA connected with me and told me about (her partner) I would have left straight away,” she said.

“Domestic violence is really difficult I was really scared to tell people.”

Ebony’s mother said she had learned lessons from the tragedy but wished she could have done more to protect her daughter.

She described Ebony as her “little princess” and that she missed her every day.

“She was always smiley and bubbly. There is not a day go by where I don’t miss her,” she said.

Ebony’s great aunt, who cannot be identified, labelled Families SA and NSW Department of Family and Community Services as incompetent and called for staff to be sacked or retrained.

“I’m very angry and I will never stop being angry and I don’t know how those workers, who more or less turned a blind eye, manage to sleep at night,” she said.

She welcomed deputy State Coroner Anthony Schapel’s recommendation to establish a national child protection database.

“It’s definitely needed ... no matter where they go it should be common knowledge what they have done in their past,” she said.

Child Protection Reform Minister John Rau said each recommendation would be thoroughly and appropriately considered.

“The Coroner has made several significant recommendations that impact across a number of Government agencies,” he said.

“Once the Government has had an opportunity to consider them, it will respond as quickly as practicable.”

An SA Police spokeswoman said it would carefully examine the recommendations.

“It should be noted that SAPOL has already taken a number of steps to address issues relating to what has been highlighted in the Coroner’s report,” the spokeswoman said.