A coroner has handed down her findings about the Murray River tragedy

A coroner has made a string of recommendations to authorities following the shocking case of a five-year-old boy being drowned by his mother on the Victoria-NSW border.

A coroner has made 17 recommendations to authorities following the shocking case of a five-year-old boy being drowned by his mother on the Victoria-NSW border several years ago.

The wide ranging recommendations aim to address the potential shortcomings of police, child protection and health workers to ensure such a tragedy does not occur again.

The coroner’s findings reveal the mother picked her two young sons – who cannot be named for legal reasons – up from school on the afternoon of Wednesday, March 1, 2017.

With their grandmother, who was in the process of seeking permanent custody, increasingly worried when they did not return home, she notified police.

The documents reveal while police followed up the reports, they did not believe the children were at risk.

After staying the night at a caravan park, the mother – who had been released from custody just weeks earlier – took her children to a friend’s Moama property about 5.30pm the following day.

Shortly after arrival she walked her sons down to the banks of the Murray River before attempting to drown her eldest son, then aged nine.

Victorian Police divers searched the Murray River for the missing boy on Friday, March 3, 2017, in Moama, New South Wales. Picture: Hamish Blair

The boy was able to break free but was then mauled by a dog belonging to the property owner – sustaining serious injuries.

Moments later, about 6.15pm, the mother held her five-year-old son under the water until he “stopped resisting”.

Emergency services scoured the area for the little boy’s body in the days afterwards.

His small body was found by police divers around 11.30am on March 4 – about 400 metres downstream from where he was drowned.

The mother, who also cannot be named, was unanimously found not guilty of murder due to mental illness in 2018. The court had heard she believed she needed to drown the boys to protect them.

NSW State Coroner, Magistrate Teresa O’Sullivan, on Friday handed down her final findings after the conclusion of an inquest into the tragedy.

The inquest – which ran from May 17 to 27 at Deniliquin Local Court last year – examined 28 issues.

It heard NSW child protection authorities had received multiple reports about the children over the years, including about the mother’s deteriorating mental health, ice use and violence but that agencies had not always recorded “valuable information” about the children’s welfare and concerns of others, including their grandmother.

It had also explored the “potential shortcomings” and “inadequacies” of various agencies and organisations involved with the boys’ mother leading up to the incident.

Emergency services during the search. Photo: Supplied

It examined the steps taken when the mother was released on parole in February 2017 and the adequacy of Community Corrections’ procedures, as well as the steps taken by the department in relation to the grandmother’s efforts to obtain permanent custody of the children.

It also explored whether NSW Police should have taken steps to have the children protected through court orders, the adequacy of their response to the grandmother’s concerns when the children went missing and the issues of cross-border policing in Echuca and Moama and communication between the NSW Police Force and Victoria Police.

Coroner O’Sullivan on Friday said the playful and outgoing little boy – who was always carrying a truck or ball – was a “much loved younger brother” who was “adored” by his grandparents.

“He was described as full of life from an early age and loved playing games and attending the local park,” she told the court.

She noted his grandparents had conducted themselves with “dignity and grace” throughout the inquest despite their continued, “unmistakeable and palpable” grief.

“The heartache continues to be felt by his family and the wider Deniliquin community.

“In making these findings I offer them my sincere and heartfelt condolences.

“It is hoped that from the inquest process comes some small measure of solace in the form of information, answers and agency accountability.”

Coroner O’Sullivan’s wide ranging recommendations were directed to an array of agencies – including NSW and Victoria Police, the Emergency Service Telecommunications Authority, the Department of Communities and Justice (DCJ), Murrumbidgee Local Health District (MLHD) and the Catholic Education Office.

Tributes at the house. Picture: Hamish Blair

The recommendations included for the various agencies to consider using the case for training purposes.

Among the recommendations were for DCJ to ensure its officers received training about the steps to be taken if a child was removed from their usual place of residence, being aware of the availability of warrants and orders and having communications strategies in place in communicating with police and other departments.

It was also recommended NSW Police review its domestic violence operating procedures and training to ensure the significance of children was understood, in addition to clearer guidance around when a child being taken by a parent should constitute abduction.

Another recommendation was for MLHD to write a protocol concerning the transfer of information between Corrective Services NSW and itself for when people are released from custody.

It was also recommended the Catholic Education Office review its Child Protection Policy to stipulate that when a mandatory report is made, that it should be followed up with a Triple-0 call.