Coroner lists ‘blatant failures’ in Child Safety’s handing of Mason Lee case

A coroner has labelled Child Safety’s handing of the Mason Lee case as a “failure in nearly every way possible”. Here we list 36 blatant failures by the department.

CORONER Jane Bentley has released more than 30 blatant failures by Child Safety workers in their handling of the Mason Lee case.

Ms Bentley said “although the handling of Mason’s case was a failure in nearly every possible way by the relevant employees of the department to comply with their statutory obligations, their manual, their policies and procedures, there are some failures which are so concerning that they require highlighting”.

Mason Lee death: Coroner hands down findings in horrific child abuse case

How the system failed slain toddler Mason Lee

Safety officers checked on Mason Lee once when he should have been seen 12 times

Toddler Mason Lee was found dead at a home north of Brisbane on June 11, 2016.

These are 36 of the worst:

• Under Child Safety guidelines, Mason should have been seen face to face 12 times by a CSO (Child Safety Officer) between March 15, and June 11, 2016 when he died. He was only seen once for about five minutes from the front door of his home where two CSO’s noticed he was walking awkwardly but didn’t ask to check his injuries despite knowing his history of nappy rash which had been compared to acid burns. Shockingly – the pair even laughed about the boy’s injuries in the car afterward, joking about asking Ms Lee “Like, can you show us your baby’s arse …. but we didn’t ask”

• On March 7, 2016 CSO3 told doctors to discharge Mason to the care of Ms Lee – at that time she didn’t know Ms Lee’s address – when she went to interview Ms Lee that afternoon she had to go to an old address and ask a neighbour where Ms Lee lived.

• On March7, 2016 CSO3 deemed all four of Mason’s siblings safe without sighting or checking on any of them and after conducting an interview with Ms Lee in the presence of Mr O’Sullivan during which she accepted facts which were patently inconsistent with those provided by medical staff – this had detrimental consequences for Mason.

• On March 8, 2016 CSO3 completed and submitted a safety assessment deeming Mason “safe” despite the concerns of his treating doctors and medical staff that he was at risk of severe neglect and despite not seeing him or visiting the home that day.

• CSO3 commenced and completed the I&A (Investigation and Assessment) and made the decision that Mason could be discharged to the care of Ms Lee without reading the information the department held about the family and without considering the medical records. On her own admission, “it was more about getting out there and … completing initial steps rather than … reading through all that information.”

• The Ethical Standards Unit (ESY) found STL4 (Senior Team Leader) and CSO3 “did not apply any methodical thought to Mason’s immediate and ongoing safety needs, prior, during and after his hospital discharge to his mother’s care” – this is obviously the case.

• CSO3 did not advise RAI1 (a Social Worker employed by Mission Australia) that Mason was discharged from hospital.

• STL1, 2 and 4 shuffled documents requiring assessment and approval between themselves from March 8, 2016 until June 2 2016 – they could provide no good reason for doing so.

• Mason was not sighted during the home visit on 9 March 2016.

• CSO3 and STL1 made the decision that an IPA (Intervention with Parental Agreement) would be commenced at the SCAN (Suspected Child Abuse Network) meeting on 15 March 2016 without any prior discussion or consideration and on the basis that the other representatives wanted an answer as to how the department was going to be involved.

• None of the three STLs who received information from SCAN team members for the meeting on 15 March 2016 sent it to the case worker, CSO3 and she did not access it herself.

• On 18 March 2016 the home visit was cursory (taking five minutes) and insufficient and CSO3 and CSO5 did not ask to see Mason’s injuries despite the fact that he could not walk properly. There was no preplanning or discussion prior to the visit.

• The ESU investigators stated: It is not apparent from departmental records that from this time any departmental officers, sighted him and the injuries to his bottom and leg, remembered him or his name, or determined his whereabouts, care provision or wellbeing during the IPA case, despite the high risk of ongoing harm and his exceptionally vulnerable medical state as a result of neglect.

• CSO3 failed to acknowledge or follow up serious disclosures by another child during the interviews on 24 March 2016 – she in fact insistently ignored them and provided information to STL1 for the next scheduled SCAN meeting in which she said that no concerning disclosures had been made by the siblings.

Timeline for Ryan Hodson/mason lee case

• Mr O’Sullivan’s son was never interviewed despite CSO3 being told that Mr O’Sullivan was concerned about what he would say if he was.

• The SCAN meeting scheduled for 29 March 2016 should not have been cancelled – there was no requirement in the SCAN manual for cancellation of an inquorate meeting.

• CSO3 told RAI1 not to attend the SCAN meeting of 12 April 2016.

• On 5 May CSO3 and CSO5 interviewed Ms Lee who said Mason had developed a massive rash on his bottom – despite being aware of his recent serious injuries they did not ask further about this, neither did they ask where he was even though he was not with his mother and he was 21 months old and he was the subject of an IPA which required face to face contact with him.

• The fact that Mason was to attend a follow up appointment at the hospital on 7 June 2016 was known to the department. Mason did not attend. If inquiries had been made by a CSO who asked to see Mason, his bruises and injuries would have been evident. Had he been taken to hospital on that day it is more likely than not that surgery for his abdominal injuries would have saved his life.

• On 8 June when CSO6 and CSO1 saw Ms Lee they didn’t ask about Mason or his whereabouts.

• On 9 June 2016 CSO4 and CSO6 were told about serious domestic violence by Ms Lee but did not consider or assess the safety of the children.

• On 9 June when STL3 and STL1 decided to approve the I&A they had no real discussion about it and did not discuss the appropriate level of intervention for Mason.

• On 10 June when CSO6 and CSO4 saw Ms Lee in the street without Mason they didn’t ask about his whereabouts or welfare. Had they done so and gone to Mr O’Sullivan’s house or requested police to attend, it would have been evident that Mason required hospitalisation.

• Later that afternoon (10 June 2016) CSO6 was told by Ms Lee’s neighbour that Mr O’Sullivan was dangerous and violent and was holding Mason hostage but took no action to assess Mason’s safety and went home.

• CSO4 was told by CSO6 about the information received from the neighbour and also took no action and didn’t consider it any further.

• The department held information that Mr O’Sullivan had a pathological jealousy, had threatened to skin his wife and kill his children when they had separated and that his “homicidal-suicidal ideations” were in the context of a situational crisis, however, in early June when they were told by Ms Lee that she was leaving him, that he was jealous, paranoid, using ice and violent none of them considered that her children might be at risk of harm from him – none of the CSOs or STLs had read the information. This had detrimental consequences for Mason.

• CSOs who accompanied the primary CSOs to home visits and interviews considered that they were only there to take notes and record conversations. Despite this erroneous view (they were CSOs with the same duties as the allocated officer) the notes that they did take were extremely deficient.

• CSO6, who had a Masters degree in social work and had worked with the department since June 2015, had completed most of her training and was being allocated cases, stated she did not know what a CPO was or the difference between that and an IPA at the time of Mason’s death.

• CSO6 thought her only job was to check on Ms Lee when she went to see the family and although she saw Ms Lee on three consecutive days during which Ms Lee made very concerning disclosures regarding DV, CSO6 did not make a single case note until after Mason’s death.

• CSO6 apparently had no idea of her basic role or even that her job was the protection of children – when asked to do a safety check of the family she thought she was just going there to see if Ms Lee was ok – “whether [she] was there … and whether she was alright”

• CSO6 was told Mr O’Sullivan hated Sibling 1 but didn’t consider that was a risk to that child.

• On 8 June 2016 CSO6 was told that there was another child (being Mason) but didn’t ask where that child was – “I did not think any more of it then. When she said I have one more, nothing stood out … there was (sic) no questions in my head at that time”.

• CSO6 had “no questions” because she had absolutely no knowledge of the Lee family because she had read none of the information held by the department and asked no questions before going to visit them – she did not even know of the existence of Mason although he was the reason for the IPA that she was told would be allocated to her.

• On 9 June 2016, when she updated STL1 and STL2, CSO6 was still not aware of Mason: “there was a name, Nathan, on the ICMS and there was Mason. So I don’t remember when I discussed it … I’m not sure whether … he was Mason or whether the child was Nathan.”

• On 10 June 2016, after being told by Ms Lee’s neighbour that Mr O’Sullivan was holding Mason hostage, CSO6 didn’t tell anyone about that information or seek to have police check on Mason and said that the conversation did not indicate to her that Mason was in danger. Incredibly, she told the ESU investigators: And I was going home … and there was nothing, no urgency in [the neighbour’s] call, she was just returning my call because I’d left a card It never crossed my mind that William was looking after Mason. That is what I knew later, that he was with him. Otherwise .. there was nothing indicating that the child was being neglected from conversations I had with the mum and … whatever information I had about the partner … [Ms Lee] said things like he is only violent when he is on ice, otherwise he’s really good, I still love him and he loves me.

• When asked if she had failed to protect Mason, CSO6 failed to show any understanding of her role even after Mason’s death and answered, “I can’t say yes to that …. I did my best.”