Toddler death exposes fatal flaws in Victoria child protection system

The “preventable” drowning of a two-year-old boy in regional Victoria has exposed serious flaws in the child protection system.

The death of a two-year-old boy in regional Victoria has exposed serious flaws in the state’s child protection system.

The death of a two-year-old boy in regional Victoria has exposed serious flaws in the state’s child protection system.

A coroner’s report says the department failed to respond to the unfolding tragedy despite six warnings.

A massive number of reports and “finite resources” such as limited staff are among the problems exposed during the inquest.

It comes after revelations that 100 children known to child protection services have died in the past two years, with SIDS/SUDI and suicide the most common causes.

The body of the toddler was found in a dam by his older half-brother on August 27, 2020, three hours after his mother fell asleep with him on the couch.

His death came after six reports to child protection, which closed his file five times despite “ongoing concerns involving neglect, alleged exposure to parental substance abuse, mental health issues and cumulative harm,” the coroner found.

Coroner David Ryan said the boy was a “very vulnerable child who was living in an environment of ongoing parental neglect.” Picture: istock

The Coroners Court detailed repeated shocking reports to authorities about the toddler, labelled “Child C”.

He was found walking along a rural highway “unsupervised, with the family dog, and wearing only a nappy” just six months before his death.

Despite a police visit finding “the house was very messy with junk piled up at the door and ants crawling around everywhere”, child protection closed its report.

A sixth report of concern about the “home environment and parenting capacity” led to an inspection where the mum told authorities her children were “sometimes” supervised when they went in the dam, which was not fenced.

Less than two months later, Child C drowned in the same dam as his family refused to engage with authorities in their report, which remained open.

Coroner David Ryan found a failure by child protection to appreciate the “significant risk” to the boy and escalate his case played a role in his death.

“I find that Child C’s passing was clearly preventable, with the principal cause being a lack of parental supervision,” the Coroner found.

“This case has highlighted a number of missed opportunities that were available to child protection to provide more effective care to a very vulnerable child who was living in an environment of ongoing parental neglect.

“However, I acknowledge that child protection practitioners are engaged in an extremely challenging task on a daily basis and with limited resources.”

The Coroner also found that the older half-brother, who found Child C’s body in the dam, had himself nearly drowned in a neighbour’s dam when he was three years old.

Information provided by the Department of Families, Fairness and Housing to the inquest painted an alarming picture of a system under immense pressure with “finite resourcing”.

“It is noted that there are approximately 130,000 intake reports every year, with approximately 25,000 open cases that Child Protection is managing with a workforce of approximately 2193 staff,” the coroner said.

“This resourcing capacity affects the delivery of child protection services across the state and the limitation is generally greater in rural areas, where it is particularly difficult to recruit and retain practitioners.”

The coroner did not recommend any changes because these were covered by a separate investigation from the Commission for Children and Young People.

The commission reiterated previous calls for better scrutiny of programs and information sharing. It also called for a stronger response in cases involving infants, particularly when many reports are made.

Opposition child protection spokesman Matt Bach said the system was underfunded when it came to early care and prevention.

“We clearly need to do far better in assessing the risk that young people are under and providing them the care and support they need,” he said.