The death of a 24-day-old baby might have been avoided if Child Protection Services (CPS) had properly assessed and acted upon the warning signs, a Tasmanian coroner has found.
Coroner Olivia McTaggart found infant Teegan Rose Hayes was accidentally suffocated while sleeping with her parents at their Devonport home on November 4, 2011.
She died at the Royal Hobart Hospital (RHH) two days later.
In her report, Coroner McTaggart found that Teegan’s mother, Kim Maree Fox, fell asleep still cradling the baby in her arms.
“Teegan was suffocated by the body of Ms Fox, possibly sleeping under the influence of alcohol,” the report stated.
“Due to this suffocation, Teegan suffered irreparable brain damage from which she could not survive despite the efforts of her parents and paramedics in resuscitating her and the intensive treatment provided by doctors at the Mersey Community Hospital and the RHH.
“I am satisfied, based upon all of the evidence in the investigation, that neither parent did any deliberate act with an intent to harm Teegan, and that her death was accidental,” she wrote.
Coroner McTaggart found that Teegan should not have been in the care of her parents at the time of her death due to the high level of risk to her.
Teegan was Ms Fox’s seventh child, four of whom (including Teegan) lived with her at that time.
Risk factors identified repeatedly
Tasmanian CPS (now known at Child Safety Service) records show there were 15 notifications made in respect of the family before Teegan was born.
A number of risk factors were repeatedly identified in the notifications, including:
- The incapacity of the parents to adequately care for the children by virtue of their intellectual disabilities
- Alcohol abuse by the parents, particularly Ms Fox
- Violent and aggressive behaviour of Ms Fox, including towards the children, when intoxicated
- Parental neglect and lack of supervision of the children
- Inappropriate methods of disciplining the children
- Displays of sexualised behaviours by the children
Two notifications were purportedly investigated by CPS and found to be unsubstantiated.
All of the remaining notifications were closed at the first stage in the CPS investigation process.
“CPS did not adequately respond to the numerous notifications in respect of the family before the death of Teegan,” Coroner McTaggart found.
“It might be said that had CPS properly assessed and acted upon those notifications … the outcome for Teegan may have changed because a correct risk assessment would have informed a comprehensive and assertive strategy for protection of all of Ms Fox’s younger [and future] children, including a likely application for the removal of Teegan from the family at birth.
“The question also arises whether CPS should have, in investigating these notifications, become aware of the impending birth of Teegan and intervened to protect her at the time of her birth.
“CPS was not, in fact, aware of Teegan’s birth until 4 November 2011 when she was admitted to hospital in a critical condition.”
‘Extensive failings by CPS’
“[CPS] failings reflect, in my view, entrenched systemic and cultural deficiencies in the context of inadequate resourcing,” says Ms McTaggart. (ABC News)
Coroner McTaggart referenced no specific evidence in her findings as to the reasons for the extensive failings by CPS over a lengthy period.
She instead referenced her findings into the death of baby Bjay Johnstone in 2012, where similar issues arose.
“The unfortunate fact remains that … there were extensive failings,” she found in the case of Bjay.
“Those failings reflect, in my view, entrenched systemic and cultural deficiencies in the context of inadequate resourcing.
“The evidence very strongly indicates that the pressure upon the individuals and the organisation, the inexperience and turnover of the workers, inadequate staff numbers and lack of training were constant issues preventing effective responses to the notifications.
“In such a context, the solution is not to criticise any individual but to address those issues that impacted so strongly on the inability of proper decisions being made in accordance with correct practice.”
Ms McTaggart noted steps had been made to improve the CPS, including the Government’s commitment to replace the data management system used to track cases.
Still, she made several more recommendations to better CPS’s performance such as providing ongoing training to child safety officers in “identifying and responding to situations where it is identified that an infant under the age of 12 months may be at risk due to unsafe sleeping practices”.
Government will consider recommendations
Human Services Minister Roger Jaensch said the Government would consider the coroner’s recommendations.
He said that since the election of the Hodgman Government in 2014, it had announced a “whole of government, comprehensive redesign of the child safety system called Strong Families, Safe Kids”.
“We have already invested $51.2 million to better support families and children at risk,” he said.
“As Human Services Minister, the safety and wellbeing of children are my top priority.”