Chloe Valentine inquest findings handed down by SA Coroner Mark Johns
NO child must ever suffer, as Chloe Valentine did, under the flawed practices of Families SA and the agency must be overhauled, the Coroner says.
NO child must ever suffer, as Chloe Valentine did, under the flawed practices of Families SA and the agency must be overhauled, the Coroner says.
State Coroner Mark Johns on Thursday savaged the child safety department’s policies, practices and culture over four-year-old Chloe’s death in 2012, and blasted its chief executive.
He criticised its chief executive, Tony Harrison, for turning his back on his SA Police background and allowing himself to be influenced by an attitude of “drift and aimlessness”.
Mr Harrison has not commented publicly but released a statement on Friday.
“I have been directed to prepare an urgent response to the Coroner’s recommendations for Cabinet’s consideration on Monday,” it says.
“It would be inappropriate for me to comment before Cabinet has considered this matter.”
Mr Harrison said he had met with Child Protection Reform Minister John Rau and Education and Child Development Minister Susan Close.
Yesterday, Mr Johns handed down his findings in the Chloe Valentine inquest — a scathing document that branded Families SA “broken and fundamentally flawed”.
He was especially critical of Mr Harrison, who took control of the beleaguered government department after serving as a SA Police Assistant Commissioner.
Mr Johns said Mr Harrison’s evidence during the inquest had illustrated the fact Families SA often and significantly deviated from the requirements of the Children’s Protection Act.
He said one section of the Act says social workers “must” mount a case in the Youth Court if a child is placed at risk due to a parent’s illicit drug use — as Chloe was.
“There seems to be no sense of surprise or concern that the agency was apparently not complying with it as a matter of course.”
Mr Johns noted that, when asked about it during the inquest, Mr Harrison deemed taking such action to be impractical.
“In my opinion, this is a damning piece of evidence,” Mr Johns said today.
“As a relatively newly-appointed chief executive, Mr Harrison appears to have sat down, read the Act, ‘identified’ the existence of this provision and concluded that it is impractical for the agency to comply with it.
“There seems to be no sense of surprise or concern that the agency was apparently not complying with it as a matter of course.”
He rejected Mr Harrison’s assertion that, because drug use is rife in Families SA cases, it cannot be a factor in deciding whether or not to remove a child.
“The fact that a particular social ill relating to the welfare of a child is prevalent does not mean that society should simply accept it ... that proposition is bizarre,” he said.
“Mr Harrison came from a policing background ... and when he was in that role I very much doubt that he would ever been heard to say the prevalence of drug-taking in the community would be a reason for police to stop actively policing the use and possession of illicit drugs.
“I am left with the conclusion that, in only 18 months, Mr Harrison has been so influenced by the cultural acceptance of illicit drug consumption by parents of children in the child protection system that he is reduced to expressing an opinion that would have been an anathema to him when he was Assistant Commissioner of Police.”
Mr Johns also recommended parents responsible for the death of a child should automatically lose any subsequent children from birth.
He said nothing less than “a massive overhaul” of the beleaguered agency was required, given its systemic failures, poor record-keeping and inadequate training.
He damned Chloe’s teenage mother, Ashlee Polkinghorne, as “an accomplished liar practised in deceit and manipulation” who regarded her daughter “as a possession”.
Mr Johns said the combination of that mentality, the hoodwinking of social workers and Families SA’s emphasis on preserving the family unit led to a catastrophe that should never be repeated.
“The concept of family preservation should only apply to parents who treat their child as precious — not a mere possession to be used for their own benefit,” he said.
“I am satisfied, on the evidence, that Ashlee Polkinghorne is not a fit parent.”
“The law should be amended to provide that a child born to a person who has a conviction, in respect of a child previously born to them, for manslaughter by criminal neglect, manslaughter or murder will be placed from birth under the custody of the Minister.”
Mr Johns said that, throughout the inquest, he had “steadily kept in mind” that the primary responsibility for Chloe’s “sad and tragic life” was borne by Polkinghorne.
“I have also given a great deal of thought to the fact that she will be released from prison in a very few years, and that the tragedy of Chloe’s life will likely be repeated in the likely event that she has another child.
“I am satisfied, on the evidence, that Ashlee Polkinghorne is not a fit parent.”
Outside court, Chloe’s grandmother, Belinda Valentine, wept as she called on the State Government and Families SA to immediately act on Mr Johns’ recommendations.
“These are steps that can be taken now and I think it’s really important that we start making the move now,” Mrs Valentine said.
“For us, our worst nightmare was Ashlee having another child and not having the power to protect that child. I think that recommendation is a really important one ... it protects children, it gives us some peace of mind.”
Mr Johns’ findings and recommendations arose from 26 days of evidence, from 39 witnesses, over five months.
Chloe died in January 2012, aged four, after her mother and her mother’s partner repeatedly forced her to ride a 50kg motorbike around their backyard.
Ashlee Jean Polkinghorne — who laughed as she filmed Chloe’s distress — and Benjamin Robert McPartland are serving minimum four-year jail terms for their crime.
However, the inquest heard Chloe’s death “was no accident” and could have been avoided had Families SA not “largely ignored” her needs and the risks to her safety.
“Unfortunately, Families SA took the path of least resistance and the whole history of its dealings with Ashlee is a history of drift, irresolution and aimlessness.”
In his findings today, Mr Johns said Families SA could have applied legal and policy tools to force a change in Polkinghorne’s poor parenting, but did not.
“Unfortunately, Families SA took the path of least resistance and the whole history of its dealings with Ashlee is a history of drift, irresolution and aimlessness,” he said.
He said the lack of censure, or even drug testing, in the face of “ample” evidence of Polkinghorne’s substance abuse highlighted “systemic failures” in the agency.
“In summary, it was broken and fundamentally flawed,” he said.
“Ashlee was given virtually limitless opportunities to address her problems ... the fact is she was demonstrably unable to properly care for Chloe.
“The pendulum has swung too far in protecting the ‘rights’ of dysfunctional parents.”
He said it seemed Families SA had, at times, “completely forgot” Chloe’s needs and prioritised its “softly, softly” approach to encourage Polkinghorne to work with them.
“Social workers cannot act in the best interests of a child and the child’s irresponsible parent simultaneously,” he said.
“It must be a standard approach for workers to always act in the child’s best interests only.
“Had these courses been adopted, it is easy to see the tragic outcome — namely Chloe’s death — might have been avoided.”
Mr Johns said social workers were wrong to view Polkinghorne as “a terrified kid of 16” who may be intimidated by their involvement.
Outside care agencies, meanwhile, had a “radically different perception” — one with which Mr Johns agreed.
“Ashlee’s behaviour was not that of a terrified kid, it was the behaviour of an accomplished liar practised in deceit and manipulation,” he said.
“Ashlee’s behaviour was not that of a terrified kid, it was the behaviour of an accomplished liar practised in deceit and manipulation.”
“(She was) misread completely and fooled (social workers) into thinking she had seen the error of her ways and would make positive changes.
“(It was) a fundamental mistake ... Ashlee would go on with her hedonistic lifestyle and continue to neglect Chloe.”
He said Chloe’s life “might have turned out differently” had workers acted on a recording of Polkinghorne boasting she was a better parent when high on drugs.
“The tape makes harrowing listening ... it is a rambling call from a person who is obviously drug-affected,” he said.
“It is impossible, in this finding, to convey the impression one gains from listening to the tape.”
Mr Johns singled out principal social worker Nicholas Ratsch, who drafted a “safety agreement” under which Polkinghorne could take drugs if she first found a sober person to care for Chloe.
He said that document was “another fundamental mistake”, and dubbed his attitude toward giving evidence during the inquest “poor”.
He said Mr Ratsch further worsened the situation by championing Polkinghorne in dealings with other welfare groups, and claiming those who saw evidence of neglect had trespassed in her accommodation.
Mr Johns dubbed this “foolhardy behaviour” and said it was “extraordinary" a member of Families SA staff would “adopt this kind of attitude”.
“This only made Ashlee more contemptuous of authority than she already was. It was a foolish and ultimately dangerous thing to do.”
“This only made Ashlee more contemptuous of authority than she already was,” he said.
“It was a foolish and ultimately dangerous thing to do.
“Doing (this) merely served to embolden Ashlee further in her defiance of authority figures, including Families SA itself.”
Mr Johns conceded gaps in his narrative, saying they were generated by the “appalling state of the records” and “poor note-keeping that manifests itself” in the case.
He said some incidents of potential risk and harm would, as a result, remain “a mystery”.
He said Chloe should have been removed and given to one of two people — her grandmother, Belinda Valentine, or grandfather Alan Polkinghorne.
“Yet neither option was ever considered ... the principle of maintaining Chloe in her ‘family’ situation was applied much too rigidly,” he said.
Mr Johns said the decision, by Crisis Care, to transport an infant Chloe to her mother in a chauffeur-driven car, without social worker supervision, breached the agency’s duty of care.
He said the agency had “sent Chloe as a hostage to fate with a complete stranger.”
Much of Mr Johns’ criticism was reserved for Leanne Stewart, a senior member of Families SA’s now-defunct “Strong Families, Safe Babies” team.
He said Ms Stewart’s belief she could not inquire into domestic violence allegations against Polkinghorne’s wishes, and without her permission, was “plainly wrong”.
“An organisation that is set up to investigate child protection matters cannot function ... without having a culture under which it is not only appropriate, but necessary, to ask questions,” he said.
“The fact that, three years after Chloe’s death, Families SA still has a common understanding it is not permissible ... is completely unacceptable.”
“An organisation that is set up to investigate child protection matters cannot function ... without having a culture under which it is not only appropriate, but necessary, to ask questions.”
He said her refusal to tell Polkinghorne that her new boyfriend was a violent, convicted sex offender on the grounds of privacy law was “simply preposterous”.
“On no view could any sensible person arrive at that conclusion ... it is frightening and concerning to think that Ms Stewart could reach such a bizarre conclusion,” he said.
The situation was made worse, he said, by the fact other staffers had agreed with Ms Stewart’s approach — demonstrating “serious deficiencies” in staff training.
He also rebuked Ms Stewart’s assertions that Polkinghorne’s parenting was “good enough” when compared with other cases on her docket.
“It seems to me that Ms Stewart and others in Families SA have adjusted their opinions of ‘adequate’ and ‘good enough’ markedly below (those of) the general community,” he said.
“There is a danger that the perspective of what is ‘adequate’ and ‘good enough’ is distorted in this situation.”
Mr Johns also slated social workers Craig Rainsford and Anna Clarke, who carried out a cursory investigation into Chloe’s welfare after Strong Families, Safe Babies closed its file.
“To describe this as an investigation is to glorify it with a title it does not deserve ... the resulting ‘assessment’ was not worthy of the name,” he said.
“It was full of inaccuracies ... it was an appalling document ... (its) assertions are completely wrong ... the entire exercise miscarried.
“To describe this as an investigation is to glorify it with a title it does not deserve ... the resulting ‘assessment’ was not worthy of the name.”
“This represents another lost opportunity in a long history of lost opportunities.”
In contrast, he praised former Families SA supervisor Carolyn Curtis as “an impressive, sincere, genuine” witness who was “obviously very much affected” by Chloe’s death.
He noted she had left the agency because she could not longer deal with “getting to families too late” to help at-risk children.
Mr Johns said Ms Curtis’ experience showed a need for more placement options for at-risk children.
He said Families SA needed a “massive” shift in its thinking so it would consider both grandparents and adoptive parents in such circumstances.
“Only 114 Australian children were adopted in 2009-10 compared to more than 8500 in the early 1970s,” he said.
“Permanent removal to adoptive parents must have a place in SA’s child protection system.”
He said the agency also needed to expand the use of income management, which controls the spending of targeted parents to ensure they do not waste money on drugs and alcohol.
“It is an indictment of Families SA that its practice is so completely divergent from the clear terms of the Act.”
Mr Johns said Families SA’s current policy of referring people to that program only with their consent was “unnecessary, nonsensical” and “should be cast aside”.
“If such parents are not already wasting Government benefits on such things, they have nothing to fear from income management,” he said.
Mr Johns said government agencies had “no excuse” for ignoring their “most basic obligations” under legislation and failing to act as legally required.
He said Chloe may very well be alive today had social workers followed their obligation under the Act and taken the matter to the Youth Court.
“It is an indictment of Families SA that its practice is so completely divergent from the clear terms of the Act,” he said.
Outside court, Belinda Valentine welcomed the findings.
“We feel as if Chloe has been vindicated and we, as a family, have too,” she said.
“We feel Chloe has been honoured in a really important way, and hopefully other children and other families will not have to go through this.”
She said she was confident Families SA would follow Mr Johns’ recommendations.
“Families SA is broken and it needs to be fixed,” she said.
“That will take time, and we as a society need to allow them some time to heal and retrain — but they need to show us they are doing it, it cannot be done behind closed doors.”
Ms Valentine said that, despite the trauma endured, she and her family would find the strength to move forward.
“We are actually the lucky ones because we had Chloe in our lives ... we loved her, she loved us,” she said.
“As we move forward she will always come with us and we can survive as long as she is honoured.”
“Families SA should use the opportunity of reform to become the model agency in child protection.” - Victims’ Rights Commissioner Michael O’Connell
Commissioner for Victims’ Rights Michael O’Connell urged the government to immediately adopt all of Mr Johns’ “strong” recommendations.
“Families SA should use the opportunity of reform to become the model agency in child protection,” he said.
Rachel Sanderson, Opposition spokeswoman for Families and Child Protection, said the recommendations were sensible.
“It’s time that this government took responsibility for what is, today, the end of a very sad chapter in our South Australian child protection history,” she said.
“They need to look at the recommendations and take responsibility for what has happened and they need to act on them swiftly.
“My role is to hold the government to account ... I will do everything I can to work with government to ensure that is the fastest way possible.”
Ms Sanderson said any decision on removing a future child from Polkinghorne’s care would “need to be assessed at the time”.
THE GOVERNMENT’S RESPONSE
Child Protection Reform Minister John Rau said he was “encouraged” by the Coroner’s “common sense” recommendations.
He said the State Government would consider all the proposals and he hoped to put new legislation to Parliament before the end of the year.
Mr Rau described Chloe’s death as “an appalling tragedy” but conceded the Government did not do all it could to protect her.
“I know it’s a case that’s touched everybody in South Australia,” he said.
“I can say as a parent I found it quite shocking that a young child could be treated in such a way and ultimately wind up dying as a result of what was criminal neglect.
“It is appropriate, I think, that we all acknowledge that the people who were primarily responsible for this child are now convicted.
“It is clear to me that the Coroner is saying to all of us that, with the benefit of hindsight, the state didn’t do all it could have done (to help Chloe).”
Mr Rau agreed with Mr Johns’ calls for the welfare of children to be the most important consideration.
“I appreciate the Coroner squarely focusing the attention of Government and government agencies on the welfare of the child as being the paramount consideration in any interaction the state must have with failing families,” he said.
Education and Child Development Minister Susan Close did not join Mr Rau in publicly responding to the findings but Mr Rau said the pair would work together on the Government’s response.
“I think those recommendations will assist me and Minister Close in being able to make the changes that need to be made to the system,” he said.
THE 21 RECOMMENDATIONS
STATE law be amended so children are automatically removed, upon birth, from parents convicted of murder, manslaughter or criminal neglect. He said there was no impediment to a parent seeking custody upon proof of having changed their ways.
ALL Families SA staff be “urgently re-educated” on their ability to ask questions and conduct investigations without the permission of a parent.
BOTH houses of State Parliament note Families SA’s “flagrant disregard” for the proper use of the provisions of the Child Protection Act regarding drug-using parents.
THE Minister for Child Protection Reform investigate Families SA’s annual reports as to the agency’s compliance with the Act regarding drug-using parents.
INCOME management be implemented by Families SA.
THE State Government work with the Federal Government to expand the use of income management across SA.
INCOME management be permanently adopted for use in SA.
FAMILIES SA ban the transport of a child alone, without agency supervision, by chauffeur drivers.
A REVIEW of resourcing for Crisis Care be undertaken.
STATE law be amended to recognise that the suffering of cumulative harm is a relevant consideration as to a child continuing to reside with its parent.
STATE law be amended “to make it plain” that keeping children safe from harm is the paramount concern, over and above keeping a family together.
ADOPTION be considered as an element of child protection — though Mr Johns admitted lacking “a settled view” as to how that should be implemented.
AN EFFICIENCY review of Families SA resources be undertaken.
FORMER Families SA boss Tony Kemp’s suggestions for redesigning the agency be considered and included as part of its much-needed overhaul.
CASES be allocated to one Families SA social worker throughout their duration with the agency.
CASES not be closed while a Families SA worker is still involved with a parent or child’s care.
SOCIAL workers employed by Families SA be “trained in the art of proper note-taking” with an emphasis on being “factually accurate” and clear distinction made when personal opinion has been included.
FAMILIES SA properly brief other welfare agencies so as to achieve the best possible outcomes for at-risk children.
DOMESTIC violence counselling be a compulsory part of Families SA’s dealings with all clients, and that there be penalties for those who refuse to participate.
MEASURES be introduced so that social workers are a registered profession in SA.
A MANDATORY ban be put in place prohibiting student social workers from taking on cases without direct supervision from a qualified worker.
HOW THE INQUEST UNFOLDED
During his inquest, Mr Johns investigated Families SA’s handling of 21 child abuse notices filed, about Chloe and Polkinghorne, in the years preceding the little girl’s death.
The first of those was filed before Chloe was even born, warning authorities she was an “at risk infant” due to Polkinghorne’s history of homelessness, fighting and drug abuse.
The last notification was lodged just months before her death.
Many of those notifications were classified as “tier 2”, meaning “an investigation is required” and Chloe could have been removed by Families SA workers.
Multiple witnesses told the inquest the agency failed to act upon their concerns and reports, even though the little girl was living a transient life with Polkinghorne.
They revealed the duo lived in squalid, rat-infested homes, that Polkinghorne was a drug user who ignored her child’s needs and she convincingly lied to welfare agencies.
They dubbed Polkinghorne “very good at lying and hiding things” from social workers, including her drug use and the poor state of her accommodation.
Families SA staff admitted they took a “softly, softly” approach to Polkinghorne in the hope she would “stop lying and engage” with support programs.
Instead of condemning her illegal habit, the agency drafted an agreement under which Polkinghorne promised to find a sober person to care for Chloe whenever she took drugs.
Despite her addiction, Polkinghorne was never required to undergo drug testing — Mr Johns accused Families SA of finding the task “just too hard”.
When Polkinghorne left Chloe in the care of a 15-year-old girl, Families SA arranged for a taxpayer-funded chauffeured car to return her to the “paralytically drunk” young mother.
In early 2009, Families SA dubbed Polkinghorne’s parenting “less than perfect” but “good enough” and above the threshold needed to remove Chloe from her care.
Later that year the agency learned she was living with a violent, convicted sex offender but did not remove her, as policy required his privacy be respected.
Families SA subsequently closed its high-risk file on Chloe despite her mother’s homelessness and the fact the child had not been sighted by workers for a month.
The agency did not share its knowledge of Polkinghorne’s failings with other support groups, and she went on to harass, threaten and intimidate support workers who tried to help her.
For a time, Chloe’s file was handled by a student social worker because Families SA deemed it “low risk” after she and Polkinghorne moved out of the sex offender’s home.
The student’s supervisor subsequently revealed she had resigned from Families SA because it was a “devastating” place to work, and that helping families was “practically impossible”.
She admitted putting “a positive spin” on Chloe’s case file so she could close it, but blamed the Youth Court for being “lenient” on teen mothers and making it difficult to remove children.
The supervisor insisted Families SA’s “therapeutic” program would have worked for Chloe and Polkinghorne if not for resourcing issues and changes in leadership.
Chloe’s respite carer recalled a chubby, loving, gorgeous little girl far too used to both pain and the “horrific” squalor in which she lived.
A Families SA welfare check on Chloe, weeks after her case was closed, was roundly criticised as “substandard” during a fiery exchange between a social worker and Mr Johns.
He subsequently warned Families SA’s lawyers he would order an SA Police investigation if the agency continued to fail to hand over key documents from Chloe’s case file.
Workers who checked on Chloe in 2011, meanwhile, gave evidence her situation was “not as severe” as other cases in their workload.
Families SA’s former policy director slammed the agency, saying Chloe should have been removed after the very first child abuse notification.
He dubbed Families SA “broken toxic and seduced into mediocrity”, and called for the social work profession to be regulated as it is in other countries.
One of the agencies supervisors conceded “oversights” in the actions of staff but insisted rectifying them would not have changed Chloe’s fate.
Another said she was never given “the full picture” of Chloe’s ordeal but, even if she had been, only “may have” recommended she be removed.
The Youth Court, meanwhile, dismissed Families SA’s claim that getting orders to remove children was “difficult”.
It dubbed such claims “quite fanciful” as the agency had successfully applied to remove children almost 2000 times in five years, without a single refusal.
Chloe’s grandmother, Belinda Valentine, told the inquest she does not blame Families SA for the little girl’s death, but believes it failed in its duty of care.
Two social workers were recalled to give further evidence — the first denied she had lied to the inquest while the second admitted some of her testimony was “inaccurate”.
Department for Education and Children’s Services chief executive Tony Harrison said Chloe should have been removed as an infant, in 2008, to “circuit-break” the “chaos” of her life.