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

A coroner has slammed the Department of Child Safety, saying it “failed in its duty to protect Mason Lee from the risk of serious harm” and that 21 staff failed him “in nearly every way possible”.

A CORONER has issued a scathing rebuke of the Child Safety officers involved in Mason’s case, saying they failed in “nearly every way possible”, as she handed down her findings into one of the state’s most tragic child abuse cases.

In June 2016, Mason’s stepfather Andrew William O’Sullivan struck the neglected boy so hard that his organs ruptured and left him to die a slow and painful death over days, refusing to seek help.

SCROLL DOWN TO READ CORONER’S RECOMMENDATIONS IN FULL

Today, the tragic life and death of the Caboolture toddler and those who failed him was laid bare.

“It is difficult to find any step taken in this case that was carried out in accordance with policies and procedures and correctly documented,” Coroner Jane Bentley wrote in her findings.

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“The fact that the ESU found that 21 employees of the department involved in Mason’s case (10 at CCSSC and a further 11 employees involved in intakes) failed to carry out their duties appropriately is indicative of the scale of the failure.”

It was a final act of cruelty in a life of neglect and pain for little Mason who was known to Child Safety workers.

Autopsy examinations conducted on Mason revealed that he had been severely mistreated for some time before his death.

“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,” she said.

Among the most concerning failures were Child Safety officers deeming Mason was safe without even sighting or checking on him, the same officer deeming Mason “safe” despite the concerns for his treating doctors and medical staff that he was at risk of severe neglect and not bothering to read through the family history and making “cursory” checks, not even bothering to see Mason’s injuries on one occasion where he clearly couldn’t walk properly.

Queensland toddler Mason Lee was struck in the abdomen by his mother’s boyfriend so hard it ruptured his small intestine, which led to his death from an infection in June 2016. (AAP Image/GoFundMe)

Shockingly, the day before Mason’s death, a neighbour warned a case officer about issues with the family but nothing was done.

“Later that afternoon (10 June 2016) CSO6 (Child Safety Officer 6) 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,” the coroner wrote.

“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 coroner found Child Safety Officers blatantly ignored the concerns raised about Mason by another child.

She said one child safety officer clearly “had no idea of her basic role or even that her job was the protection of children” and claimed she thought her role was to see if Mason’s mum was home and ok.

Mason’s mother Anne Maree Lee and O’Sullivan were each sentenced to nine years imprisonment over the 21-month-old toddler’s manslaughter.

During an inquest in March this year, counsel assisting the coroner Jacoba Brasch said the hearing was not the time for “vengeance and blame” but the time to uncover what could have been done differently to prevent Mason’s tragic death and help avoid other children from suffering a similar fate in the future.

Andrew William O'Sullivan, step father of Mason Lee.

Mason Lee's mother, Anne Maree Lee. Picture: 7 News Brisbane

“Your honour there is nothing to be gained from approaching any witnesses with a view to retribution or revenge, for nothing will bring Mason back to us and such emotions cloud the ability to learn,” Ms Brasch said.

“One must assume each of these witnesses, especially the child safety workers have deeply searched their soul as to what they might have done differently.”

“It may be your Honour that all the pieces of the puzzle that was Mason Jet Lee were in the grasp of authorities or otherwise easily ascertainable and it may be that no one put those pieces together to render the picture of a little boy who needed care and protection without a parent willing and able to do so.”

The inquest was cut short due to COVID-19 but it continued on the papers and Coroner Jane Bentley will this morning deliver her findings and any recommendations she deems fit.

A statement tendered to the inquest by a Department of Child Safety worker who cannot be identified revealed the Ethical Standards Unit investigated DOCS workers involved in Mason’s case with allegations substantiated against eight officers.

MP Ros Bates leads a Walk for Mason. Pic Peter Wallis

Five of those were reprimanded, one had their pay cut and another was referred to the Crime and Corruption Commission for professional misconduct.

In a report tendered to the inquest by Andrew Whittaker, the head of the Risk, Resilience and Expert Decision Making research Group at London’s South Bank University, he said a review of the case showed Mason was “hidden from view”.

“He was rarely seen, and it appears that his bedroom was not seen by a child safety worker,” Dr Whittaker said.

“When reviewing the documents, it was challenging to find references to workers observing and interacting with Mason directly.”

He said it appeared DOCS workers did not view Mason’s home beyond the main living area during visits.

“This would suggest that there was a lack of curiosity, and assumptions made that if the shared areas of the home were acceptable, the whole would be,” he said.

“In summary, Mason was on the periphery of workers’ attention rather than at the centre.”

“What happened to little Mason Jet Lee makes me sick to the stomach, he was badly let down by a system that was supposed to protect him,” LNP Shadow Minister for Health and patron of Act for Mason Ros Bates said.

“Labor has form when it comes to scapegoating bureaucrats when Annastacia Palaszczuk needs to take responsibility for her governments failures.

“Queenslanders are sick of the same old paltry excuses for Labor’s broken child safety system that has let too many vulnerable kids slip through the cracks.”

CORONER’S RECOMMENDATIONS

1. I recommend that the SCAN manual and relevant legislation, policies and procedures be amended to mandate that when a family is engaged with a service provider, and that family’s matter is referred to SCAN:

a. the external support worker must be invited to attend all SCAN meetings relevant to that family; and,

b. information held by the SCAN members must be shared with the external support worker.

The department agrees with this recommendation.

2. I recommend Queensland Department of Health implement formal policies and procedures for the escalation of a case in which medical officers disagree with a decision made by the department in relation to the discharge from hospital of a child.

Qld Health and the department agree with this recommendation.

3. I recommend that procedures and policies for the provision of information to QPS be reviewed to ensure that information held by the department is provided to the QPS, upon request, in a timely manner and without redactions and the QPS report annually for the next three years to the Coroners Court of Queensland the number, if any, of search warrants executed on the department for the provision of information in relation to children who are subject to a joint investigation.

The department submits that this recommendation is unnecessary since it is unclear from the evidence why the police officer obtained warrants for the disclosure of material in this case and it was not addressed in his evidence. However, the department provided no information which would rebut the Detective Inspector’s evidence that it is not uncommon for the department to request police obtain warrants before releasing information. I have therefore come to the conclusion that the sharing of information between the department and the QPS should be reviewed and monitored.

4. I recommend that the SCAN manual and relevant legislation, policies and procedures be amended to mandate that when a SCAN meeting is inquorate, the available members nevertheless hold a case planning discussion about the matters that would have been subject to the meeting.

The department agrees with the above recommendation.

5. I recommend that:

(a) The department review its policies and procedures to ensure that, in accordance with the Government’s acceptance of Recommendation 7.4 of the Carmody Inquiry:

i. adoption is routinely and genuinely considered as a suitable permanency option for children in out-of-home care where reunification or unification is unlikely, and should be pursued in those cases, particularly for children aged under 3 years.

ii. Adoption is routinely and genuinely considered by Child Safety officers as one of the permanency options open to them when deciding where to place a child in out of home care.

(b) The Government consider whether the Adoption Act 2009 (Qld) should similarly reflect the 2018 amendments to the Adoption Act 2000 (NSW), expecting children to be permanently placed through out of home adoptions within 24 months of entering the department’s care.

(c) The department report to the Coroners Court of Queensland the numbers of children adopted and the details of those matters, every six months for the next five years.

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