SA coroner blasts child protection system over preventable murders of Amber Rigney and brother Korey Mitchell at Hillier

The Child Protection Minister has pledged to implement a range of recommendations after savage criticism over the preventable deaths of Amber Rigney and Korey Mitchell.

Catastrophic child protection failures in the lead-up to the murders of two children had already been identified by separate coroners who each made recommendations to fix the issues - but successive governments failed to act.

Deputy Coroner Anthony Schapel found the deaths of Amber Rose Rigney, 6, and Korey Lee Mitchell, 5, were preventable and lashed governments for ignoring coronial and other recommendations that would keep vulnerable children safe.

He said “unlawful practices” with the child protection authority had continued despite coronial findings in the cases of Chloe Valentine and Ebony Napier “that identified those practices”.

SA Child Protection Department chief executive Cathy Taylor and Child Protection Minister Katrine Hildyard held a media briefing on Friday morning on their response to the inquest findings. Ms Hildyard pledged to implement all of Mr Schapel’s recommendations on child protection and launch a wider review covering all previous recommendations.

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Under state law, child protection authorities are obliged to take action in cases where they believe children are placed at risk because of their parents’ drug use.

In such situations, there is a mandatory obligation upon the Department for Child Protection to apply for an order from the Youth Court directing parents to undergo drug assessment.

The assessment can then ensure parents received appropriate treatment or periodic testing to monitor their drug abuse.

A picture from the funeral notice at Enfield Memorial Park for Adeline Yvette Rigney-Wilson and her children Amber Rose Rigney and Korey Lee Mitchell.

No application was made against the parents of Chloe Valentine or Ebony Napier, despite clear reasons for suspicion in both cases, and coroners in those matters made recommendations that authorities should strictly comply with the law.

Despite that, no application was made in the Hillier case, despite the warnings contained in those two reports, which were published within the 13 months prior to Amber and Korey’s death.

Mr Schapel found there had been “consistent” observations about Ms Rigney-Wilson’s ice usage and the effect it had on her ability to care for the children.

“That the Department continued to ignore the mandatory obligations contained in ... the Act following the Valentine finding is to be deplored,” he said.

Mr Schapel recommended that the Premier, Child Protection Minister and chief executive of the department review all coronial and other recommendations relating to child protection in South Australia, “with a view to implementation”.

Korey Lee Mitchell and his sister Amber Rose Rigney were known to be at risk of abuse but the state coroner has found Families SA did not act to keep them safe.

“What this inquest has highlighted is the folly of governments ignoring coronial and other recommendations,” Mr Schapel said.

“In my opinion what is required is a broad review of all coronial and other recommendations ... relating to child protection.”

Outside court, the children’s grandparents, Steve Egberts and Janet Wells, issued an emotional plea for the government to take strong action on the issue.

“It was urgent when it happened to Amber and Korey, as far as we’re concerned,” Mr Egberts said.

“It’s a bit baffling why (the department) would be so hesitant to protect children, but we would actually call on the current premier to take heed of what both the Ombudsman and the Coroner have pointed out.

Janet Wells and Steve Egberts called on the government to take immediate action to protect children. Picture: NCA NewsWire/Brenton Edwards

“It’s blatantly obvious what needs to be done here. We need an overhaul.”

Ms Wells said it was “time to demand that changes happen”.

“Amber and Korey didn’t deserve this, and there’s no other children that should deserve the same thing either,” she said.

“It made me sick, it made me absolutely sick to know that Amber and Korey were nothing to (the department).”

The scathing findings came on the first anniversary of the murder of baby Kobi Shepherdson – another child failed by the system. The Advertiser is investigating the failure of successive state governments to implement crucial child protection measures in a five-part special report.

Mr Schapel also recommended a full review should be undertaken to make sure Child Protection Department procedures are compliant with legal obligations.

Amber and Korey were strangled to death by Steven Graham Peet, the partner of their mother Adeline Yvette Wilson-Rigney, who also killed Ms Wilson-Rigney on May 20, 2016, at their Hillier home in Adelaide’s north.

The inquest specifically probed the involvement of Families SA with the family.

It was told that a “cluster” of notifications regarding Amber and Korey’s care was received by Families SA, including two that were considered “tier 2”, between October 2015 and February 2016.

But Families SA took no action because of a lack of resources.

Asked about the findings, Premier Peter Malinauskas said the deaths of the children and their mother were an “absolute tragedy”.

Adeline Rigney-Wilson and her children were murdered by her partner Steven Graham Peet, who is serving a life sentence.

“There are recommendations that refer directly to the Premier and those are ones I’ve already sought a briefing on and I will have more to say about that in due course,” he said.

“But, needless to say, when we see such a significant tragedy unfold, where there was an intersection between the victims and access to government services, that necessitates a response and the coroner’s inquiry can help inform that.”

Mr Malinauskas said his government would be thoroughly scrutinising the recommendations made by the coroner.

“It’s important we take those recommendations seriously and respond accordingly,” he said.