A West Australian coroner says the Department for Child Protection (DCP) failed to provide adequate care and supervision for a 21-month-old Kalgoorlie girl who died from cardiac arrest in 2012.
KLD, as she is known for legal reasons, was under the Department’s care when she was brought unconscious to Kalgoorlie Hospital on August 16, 2012, after falling from a couch at her foster parents’ home in Kalgoorlie-Boulder.
She was pronounced dead five days later with the cause of death ruled to be prolonged cardiac arrest brought on by a sudden head injury.
Handing down her findings on Friday from her inquest earlier this year, deputy coroner Evelyn Vicker said the DCP failed to respond to ongoing trauma that contributed to the girl’s death.
“It is likely KLD’s death was the result of a culmination of traumatic injuries which led to a final systems overload for which her system was unable to compensate,” Ms Vicker said.
“[It] really reflects a lack of ongoing supervision, treatment and care, more than one isolated inflicted traumatic injury would have.”
Coroner distressed by lack of proper care
The inquest was told the girl, a ward of the state since she was five months old, was left without a permanent case worker when she and her brother were transferred from Joondalup to Kalgoorlie in 2012 in a bid to bring them closer to her biological parents.
Ms Vicker found that period coincided with an ongoing decline in the baby girl’s health that her biological parents noticed but the Department failed to act on.
“A child in the care of DCP … should not have to rely on the input of parents from whom she was removed to ensure proper care,” Ms Vicker said.
“I find it extremely distressing the resource situation in Kalgoorlie DCP was such that there were 100 children on the monitored list, presumably all receiving reduced care on the part of DCP, as observed in this case.”
DCP officials told the inquest its Kalgoorlie office was suffering from a 30-40 per cent vacancy rate at the time of the girl’s death, but procedures had since been improved.
She recommended a string of changes to DCP procedures including mandatory paediatric assessment and full-time caseworker for children in DCP care being shifted to new families or locations.
Ms Vicker also called for all contact between the Department’s workers and children in care be recorded and properly assessed to ensure adequate care and treatment was being provided.
Foster parents ‘unable to cope’: coroner
Ms Vicker said the lack of intervention from the Department left the 21-month-old’s foster parents, who cannot be identified for legal reasons, struggling to deal with the pressure of caring for both KLD and her brother.
She said the foster mother’s advancing pregnancy meant KLD was often left in the care of the couple’s other children, none of whom were older than 11.
“It was clear the children were well-loved,” Ms Vicker said.
“But with appropriate review, it would have become clear that KLD was not being cared for or supervised appropriately.”
She said it was possible the girl may have been “picked on” due to her status as the youngest child in the household.
The 21-month-old suffered a succession of injuries and illnesses while in foster care in Kalgoorlie, with the lack of treatment contributing to the “overall decline” in the girl’s condition.
But while Ms Vicker would could not rule out those injuries having been deliberately inflicted, conflicting medical evidence lead her to deliver an open finding on the factors behind KLD’s death.