Inquest into the death of Baby Q

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Baby Q Hearing dates: 18 – 22 December 2023 State Coroners Court, Lidcombe Date of findings: 18 April 2024 Place of findings: Tamworth Local Court (by AVL to parties located elsewhere) Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – manner and cause of death – mental illness – family violence and neglect – family known to the NSW Department of Communities and Justice and the QLD Department of Child Safety, Seniors and Disability Service – neglect – cumulative harm – NSW Police Force – QLD Police Service – cross-border policing – information sharing File number: 2018/359588 Representation: 1. Ms D Ward SC and Ms M Barnett SC, Counsels Assisting the Coroner, instructed by Alexander Jobe and Elizabeth May (Department of Communities and Justice (‘DCJ’))

2. Mr Jake Harris for DCJ, instructed by Darren Chennell (DCJ)

3. Karen Carmody for the QLD Department of Child Safety, Seniors and Disability Service (‘DCSSDS’), instructed by Chantal Howland (DCSSDS)

4. Jillian Caldwell for the NSW Police Force (‘NSWPF’) instructed by Jesse Pereira, Wotton + Kearney (NSWPF)

5. Mark O’Brien for the QLD Police Service (‘QPS’)

6. Jaimee-Lee Jessop, Gilshenan & Luton Legal Practice, for QPS Officers Bisa and Barton (limited leave granted)

Non publication order: Non-publication orders made on 18 December 2023 prohibit Baby Q LB the publication of any information that identifies or parents.

Non-publication orders made on 18 April 2024 prohibit the publication of the name of a DCJ caseworker.

A copy of the orders can be obtained on application to the Coroners Court registry.

Findings: The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an Baby Q inquest into the death of Identity Baby Q The person who died was Date of death She died on 17 November 2018 Place of death She died at Tweed Heads, NSW Cause of death The cause of her death is unascertained Manner of death Baby Q was a child known to child protection authorities.

B aby Q and her family were also known to Police in Queensland and NSW, and her mother and father were known to mental health services in various states. She was killed by her father who was suffering severe ppssyycchhoossiiss.

Recommendations: To the QLD Director-General, Department of Child Safety, Seniors and Disability Services

1. In situations where DCSSDS refer a family to a family well-being service in the course of an Investigation and Assessment, consideration be given to requiring the family well-being service (however described) to inform DCSSDS if the family disengages prematurely from the service and the reason for the disengagement.

2. That consideration be given to improving access for DCSSDS caseworkers to expert psychological opinion to help them assess risk to children, when working with a family with complex mental health needs.

To the NSW Secretary, Department of Communities and Justice, and the Commissioner of the NSW Police Force.

3. That consideration be given to amending ChildStory so that if an Assessment Officer in a Child Wellbeing Unit makes an entry under the CWU tab for a family where there is an open file at a CSC, the CSC is automatically alerted to the entry having been made (for example, recording contact with the family and concerns assessed as non-ROSH).

4. That consideration be given to trialling an information sharing portal that gives DCJ direct access to limited but relevant information on CoPS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of Part 16A requests. The Queensland Self Service of Document Retrieval and Unify initiatives provide a useful precedent.

To the Commissioner of the QLD Police Service, and the Commissioner of the NSW Police Force.

5. That a proposal be taken by QPS and NSWPF to the Australian Criminal Intelligence Commission, which oversees the National Criminal Intelligence System to trial an information sharing portal that would permit state and territory child protection authorities to have direct access to limited but relevant information on NCIS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of further lawful requests for information under state or territory law.

Table of Contents Baby Q Issue 1: Can the cause of death be ascertained? What evidence Baby Q supports or detracts from a finding that died as a result of drowning or as Baby Q Issue 2: What did father do on 17 November 2018 to cause her death Baby Q Baby Q Issue 3: What happened to and her family on 16 November 2018 after Issue 4: What other involvement did Queensland and/or New South Wales Police Baby Q have with parents in the period September – November 2018 and did Issue 5: What new information did the Queensland DCSSDS and/or the New Baby Q South Wales DCJ learn about and her family circumstances in the period Baby Q Issue 6: Was information about and any risks posed by her family adequately shared across state boundaries and between Police and child welfare Baby Q authorities? Did state boundaries impact upon the response to and her Baby Q

The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of Baby Q Introduction

1. This inquest concerns the tragic death of a nine-month-old First Nations baby girl, Baby Q (born 2 February 2018). Baby Q was killed by her father, RB on the evening of 17 November 2018. RB was suffering a psychotic episode at the time. Baby Q body was found on Main Beach, Surfers Paradise, Queensland on 19 November 2019. The factual matrix surrounding those events is set out in the decision of Her Honour Justice Wilson in R v RB [2020] NSWSC 1552, in which a special verdict of not guilty by reason of mental illness was returned.

2. At the time of her death, Baby Q her parents and her LB were living rough and sleeping in a park. For all of Baby Q short life, the family were transient, living between Geelong, Victoria, the border towns of northern NSW and Queensland and Mackay, Queensland. Both parents suffered from severe mental illness, and RB was also dependent upon alcohol and frequently used cannabis. Multiple government agencies in NSW and QLD, including NSW Department of Communities and Justice (DCJ), Queensland Department of Child Safety, Seniors and Disability Service (DCSSDS), New South Wales Police Force (NSWPF) and Queensland Police Service (QPS) were involved with or had some contact with the family leading up to Baby Q death. The family also had limited contact with non-government support services from time to time.

3. Unfortunately I know very little about Baby Q personality and character. I note photographs of Baby Q contained in the brief show her chubby cheeked and smiling. There is evidence that she was observed as looking happy at various times. Her maternal aunt described her as a “happy healthy baby”.

4. If Baby Q had lived, she would have turned six years old in February of this year and could have been a few months into Year One. In making these findings, I offer Baby Q family my sincere and heartfelt condolences for the profound loss they have suffered.

The role of the coroner and the scope of the inquest

5. The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death.1 A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future.2

6. Pursuant to s 24(1)(b) of the Coroners Act 2009, only a senior coroner has jurisdiction to hold an inquest concerning a death or suspected death if it appears to the coroner that the person was (or that there is reasonable cause to suspect that the person was) a child to whom a report was made under Part 2 of Chapter 3 of the Children and Young Persons (Care and Protection) Act Baby Q 1998 within the period of three years immediately preceding their death.

falls into this category. There is a clear public interest in ensuring that the death of a vulnerable child, who has previously been reported to DCJ is fully investigated to ascertain whether the state should have provided greater assistance or whether missed opportunities for care and support can be identified and rectified for future children.

7. It is important to acknowledge at the outset that these proceedings were approached in a cooperative manner by each of the involved parties. The court was also greatly assisted by the provision of internal review reports that were produced by both DCSSDS and DCJ and which indicated their commitment to Baby Q a full and open review of the circumstances of death. It was heartening to hear of improvements that have already been made to systems following these internal reviews.

Baby Q

8. family were homeless or in extremely precarious housing in the period leading up to her death. Their life was frequently transient, and they were often difficult to contact. I acknowledge this created particular difficulties for those trying to offer the family support and impacted upon the continuity and quality of the assistance provided. Homelessness and the lack of appropriate 1 Section 81 Coroners Act 2009 (NSW).

2 Section 81 Coroners Act 2009 (NSW).

accommodation for families in need is an issue of growing concern in our Baby Q community and one that continues to impact children like

9. It is important to acknowledge at the outset that while homelessness was one significant issue the family faced, their difficulties were much more complex. It may be that focus on the family’s homelessness at times even contributed to an inadequate appreciation of the real effect of their parents’ mental illness on Baby Q LB RB JM and Both and were extremely unwell and Baby Q RB were untreated at the time of death. illness often manifested JM in aggression and violence, and while agencies regarded as a protective influence in the family, she too was unable to provide appropriate care to the children she clearly loved.

Baby Q

10. death was impossible to predict. However, an examination of the material before me makes it clear that the risk of some kind of harm occurring to her was entirely predictable, indeed inevitable without significant intervention in the family. While I accept that no single person had all the relevant information indicating the extent of the escalating risk involved, various people who had Baby Q interacted with the family throughout 2018 should have understood that was a child in urgent need of protection. Given the nature of this family’s fractured involvement with child protection services and police in various states over the years, the court was particularly keen to understand and assess the systems for information sharing between the relevant agencies.

11. A list of issues was prepared before the proceedings commenced. These issues guided the investigation and focused on the family’s involvement with the Baby Q relevant government agencies in the period leading up to death, Baby Q cause and manner of death, information held by the agencies Baby Q LB regarding risks posed to the and whether information was adequately shared across State boundaries, and what changes have been Baby Q implemented since death.

The evidence

12. The court took evidence over four hearing days. The court also received extensive documentary material, estimated at over 50,000 pages. The material included witness statements, government and non-government organisation LB

records concerning the family, medical records, CCTV and Police body-worn camera footage, various policy and procedures, and a report of an independent expert, Dr Alison O’Neill, Clinical Psychologist.

13. The inquest heard oral evidence from eight witnesses; three of whom met Baby Q and her family in the weeks leading up to her death and on the day she died, four organisational witnesses from the respective child welfare and police agencies, and one independent expert witness, Dr O’Neill.

14. While I am unable to refer specifically to all the available material in detail in my reasons, it has been comprehensively reviewed and assessed. I acknowledge that I had access to a range of material that no individual caseworker would Baby Q have seen at the time of death.

Background and brief chronology

15. Given the significant volume of material, those assisting me drafted a chronological summary of the key events from the available documentary evidence. This summary was tendered and its content was agreed on by the parties, subject to a few minor amendments from DCJ which have now been included. I attach a copy of that document as an annexure to these reasons. I do not intend to repeat all the material contained in it. I regard it as accurate and I adopt its content.

16. For current purposes, I provide the following background and brief chronology.

Baby Q

17. was born on 2 February 2018 at Mackay Base Hospital, RB JM RB Mackay, Queensland to and and

JM LB had one other child together, who was ten months old when Baby Q was born.

RB RB Baby Q

18. (aged 47 at the time of death) is a Torres Strait Islander man who was raised in Western Australia and Queensland. He is the father of four Baby Q children: the youngest being

RB

19. It appears on the available records that was first diagnosed with alcohol induced psychotic disorder in 2000 and schizophrenia in 20013. As recorded in the decision of the Supreme Court, “throughout these years [2002-2013] RB recurring among the delusions reportedly suffered by [ were hallucinations of being commanded to kill people and to kill a baby, delusions concerning black magic, spirits, and elders and, curiously, the singer Brittney Spears”.4

20. From 20105 until November 2016, RB was “managed” (as the phrase was used within the records) via an Involuntary Treatment Order under the provisions RB of the Mental Health Act 2000 (QLD). Despite that order, would fail to turn up for his depot medication from time to time, and his compliance varied.

RB JM

21. Once and moved to Victoria in mid-2016 (discussed further RB below), started seeing a General Practitioner at the Wathaurong Health Service for his paliperidone (anti-psychotic) injections.6 Sometime after an RB appointment on 1 November 2016, travelled to Mackay and went into the Community Mental Health service on 11 November 2016 to say hello to his case RB manager. This ultimately led to the revocation of Involuntary Treatment Order.

RB

22. The Medicare records establish that did not consult a psychiatrist in the community nor a general practitioner for treatment for his schizophrenia (or Baby Q anything else) from late November 2016 until the time of death.

Medical evidence accepted in the Supreme Court proceedings established RB was actively psychotic immediately prior to his arrest on 19 November 2018.7

23. RB was also dependent upon alcohol and frequently used cannabis.8 3 Judgment, Exhibit 1, Tab 8, p.231-232 at [72]-[73].

4 Judgment, Exhibit 1, Tab 8, p.232 at [75].

5 Judgment, Exhibit 1, Tab 8, p.223 at [12]. Mackay Health Service Mackay Exhibit 1, Tab 109C, p.1808-73-1808-74.

6 Wathaurong Health Service Mackay, Exhibit 1, Tab 109B, p.1808-48.

7 Judgment, Exhibit 1, Tab 8, p.234 at [82]-[85].

8 Mackay Health Service, Exhibit 1, Tab 109C, p.1808-73.

JM JM Baby Q

24. (aged 23 at the time of death) was born and raised in JM Victoria with her parents and younger sister. had a supportive childhood and did not start showing signs of mental illness until she was 18 or 19 years old. At this time her parents noticed a rapid deterioration in her mental JM health. parents tried very hard to support her, but it was difficult given that she lacked insight into her condition.

RB JM

25. Like delusions were sometimes focused on religious or JM JM spiritual themes. According to father, became extremely religious and believed at one point that she was the mother Mary and that she was going to give birth to baby Jesus.9 She would sometimes go out to baptise people.10 JM

26. Around this time (in 2014 or 2015), went missing. This was reported JM to Police by her parents who located and took her to hospital where she was involuntarily detained. There followed various admissions to psychiatric in-patient and out-patient facilities11 and the prescription of anti-psychotic medication.

RB JM

27. After meeting in early 2016 (discussed below), mental health deteriorated again, and she was admitted on an involuntary basis to the acute care psychiatric unit of Geelong Hospital from 10 - 27 May 2016. Upon JM discharge was treated as a voluntary patient through Barwon Health’s Prevention and Recovery Centre (a sub-acute facility).12 JM

28. As at 31 May 2016 was being treated for a mental illness consisting of mood disturbance (manic episode) and psychotic symptoms. A medical report prepared for the Victorian Civil and Administrative Tribunal suggested this was most likely Bipolar Affective Disorder Type 1, but confirmation of this diagnosis 9 Exhibit 1, Tab 105, p.1744 at [21].

10 Exhibit 1, Tab 105, p.1744 at [23].

11 Exhibit 1, Tab 105, p.1743-1745; at p. 1743-1745; Exhibit 1, Tab 105A, p.1755-1756; Exhibit 1, Tab 106, p.1758.

12 Exhibit 1, Tab 106, p.1959 and 1780.

needed further longitudinal assessment. A differential diagnosis included delusional disorder.13 JM

29. At a later point in mid-2016 was discharged from the Barwon Centre to a community based mental health treatment service in Belmont.14 JM

30. Little more is known about treatment. There is nothing to suggest she received psychological or psychiatric care following this time, including in Baby Q the lead up to or following birth. In the criminal proceedings after Baby Q JM death, it was accepted that had been suffering from an untreated psychotic condition for several years.15 It is likely she lacked insight into her condition.

JM RB

31. There is evidence that was subject to violence from and that she sustained injuries, such as cigarette burns and other injuries which are likely to have been perpetrated by him. She is reported to have taken a subservient

RB JM role to him. Both and had very significant mental health issues and it is difficult to untangle the way in which family violence became incorporated in or interacted with their personal and shared delusions.

JM

32. was not a known user of illicit drugs or alcohol. She was intelligent and educated and it appears likely that she became skilled at hiding aspects of her delusions in an attempt to keep her family together. There is evidence that she had a strong bond with her children and tried, as best she could, to protect them.

RB JM and meet and commence a relationship JM

33. In early February 2016 moved to the Gold Coast to study. Shortly RB RB thereafter she met at Surfers Paradise beach. was homeless at the time. Within about two weeks, an intimate relationship developed.

JM RB abandoned her studies and job and travelled to Mackay with JM

34. re-established contact with her parents in May 2016 and travelled RB down to Geelong with He was not introduced to her parents, but they 13 Exhibit 1, Tab 106, p.1959 and 1780.

14 JM Exhibit 1, Tab 102, p.1710.

15 Investigators note, Exhibit 1, Tab 9, p.236.

JM saw him around town and had an idea that he was partner. By this

JM LB time was pregnant with Her parents did what they could to JM support but she did not always accept their help.

JM RB

35. After and met, they drifted up and down the eastern seaboard from Mackay to Geelong and back again, then ultimately moved around the border communities of south eastern Queensland and northern NSW.

JM

36. From late May to about August 2016, became a voluntary patient and RB moved back and forth between Mackay and Geelong.16 In early September 2016, the couple moved into a rented house in Geelong.17 In LB December 2016, was born. In about September 2017, the family left Victoria for Mackay.18 The Family’s early involvement with DCSSDS

37. The inquest focused primarily upon events between September and November Baby Q 2018 being proximate to death. However, I will briefly refer to the longer child protection history in Queensland as it usefully indicates the wealth of background material that would have been available to that organisation.

Baby Q

38. One notification was made to DCSSDS in November 2017 (before was born) and two further reports were received in May19 and August 2018.20 As Baby Q above, was born in February 2018.

39. Reports in November 2017 and May 2018 were prompted by concerns around the family’s homelessness. The report in November 2017 was made by a nongovernment family wellbeing service, , and referred to, among other

JM LB things, and looking unclean, the family living out of their car, RB being diagnosed with schizophrenia and being a heavy drinker. A further notification in November 2017 was made by another non-government 16 Exhibit 1, Tab 106, p.1759 at [15].

17 JM Exhibit 1, Tab 102, p.1710.

18 JM Exhibit 1, Tab 102, p.1711 at [22].

19 QCS documents, Exhibit 5, p.165-171.

20 QCS documents, Exhibit 5, p.165-171.

LB organisation, and referred to having quite a bit of scabbing all over his body.21 JM

40. and DCSSDS interviewed on 7 November 2017, and RB completed a Safety Assessment on the same day. was interviewed on 8 LB November 2017. The Safety Assessment determined that was safe JM because, amongst other things, was now in emergency accommodation, had applied for housing and had received antenatal care whilst RB was said to be engaged with for mental health.22

41. Between 7 and 23 November 2017 an Investigation and Assessment was conducted by DCSSDS. The Investigation and Assessment was finalised on 21 November 2017, and on 22 November 2017 the Assessment and Outcome was LB approved with an outcome of ‘unsubstantiated’ in relation to whether was a child in need of protection.23

42. The family again came to the attention of DCSSDS in May 2018 when a record of concerns was received on 27 May 2018 from .24 RB

43. were alerted to sleeping rough in a park on the Gold Coast with his Baby Q RB two children. was three months of age at the time. was reportedly initially angry with Police as he thought they were going to remove the children, but he settled when offered to help him find accommodation.25

44. The notification was referred to Nerang SSC and on 28 May 2018, Child Safety Officer Greta Weertman arranged a “home visit” to the Vibe motel where the family were staying. The home visit was conducted between CSO Weertman, CSO Crystal Sanford and Tanya Blackhall from Kalwun26 with JM and RB ( sister) attending.

JM

45. was seen to have a blood shot eye with a small bruise underneath her eye. She said she got it playing football a few weeks before. 27 At one point 21 QCS SPRP, Exhibit 1, Tab 43, p. 973.

22 QCS documents, Exhibit 5, p.46-50.

23 QCS SPRR, Exhibit 1, Tab 44, p.974.

24 QCS documents, Exhibit 5, p. 82.

25 Fing, Exhibit 1, Tab 48A, p.1115.

26 Kalwun, Exhibit 1, Tab 68, p.1419.

27 Kalwun, Exhibit 1, Tab 68, p.1482.

JM during the interview stated “You’re scared of him” to which replied “ RB the head of the family. I can’t stand over him.”28

46. On 29 May 2018 the QPS provided additional information to DCSSDS including extracts from RB history and an offer to provide full history on request.29 JM On the same day contacted CSO Weertman again to inform her that the family had secured two nights of accommodation at Montego Motel in Mermaid Beach and that they had also been accepted for a property in Casa De Sol.30

47. Another home visit at the Motel occurred that afternoon with CSOs Crystal Sanford and Madeline Kelly. The resulting file note is sparse. DCSSDS JM concluded that appeared willing to engage in services and obtain housing. DCSSDS did not see or speak with RB 31

48. The next day, 30 May 2018, in response to a section 159N request, DCSSDS received information from the Child Protection Liaison Unit, Gold Coast University Hospital and Health Service, which provided information held with

JM RB RB respect to and mental health history, as well as RB substance abuse, intellectual impairment and of having three other children (the youngest being in care as at 2016).32

49. On 4 June 2018, CSO Weertman and CSO Kristy Wright attended the family RB home for an unannounced visit. was not present. The case note for this visit indicates that it focused upon checking physical arrangements for the children (bedding, clothes, food).

RB

50. On 5 June 2018 CSO Weertman had a brief telephone discussion with Also on 5 June 2018, CSO Weertman discussed the family with Tanya Blackhall JM from Kalwun who noted that had been engaging with the family wellbeing service, and RB had been “present when engaging with Kalwun”.33 28 QCS documents, Exhibit 5, p.145.

29 QCS documents, Exhibit 5, p.157.

30 QCS documents, Exhibit 5, p.115.

31 QCS documents, Exhibit 5, p.118-122.

32 Brewer, Exhibit 1, Tab 48, p.1088.

33 QCS documents, Exhibit 5, p.138.

51. On 7 June 2018, the DCSSDS Investigation and Assessment into the May 2018 notification was finalised with an outcome of ‘Unsubstantiated - Child not in Need of Protection’.34 The family risk evaluation neglect risk score was recorded as JM moderate. It was said that the protective capacities of allowed her to RB provide adequate protection of the children. It was noted that consumes “alcohol outside of the home.”35 Various factors were recorded as being JM strengths and resources, these included that had engaged well with

RB JM Kalwun, she had secured a bond loan, neither nor were TICA JM listed, and had a good rental history in Mackay and Victoria and that had re-engaged with her parents.36

52. I accept counsels assisting’s submission that the logic underpinning the assessment was flawed in a number of respects. Of particular concern was the JM reliance placed on contact with Kalwun. The circumstances of this re-engagement was only in its infancy and was essentially untested. As it JM happens, Kalwun’s meeting with on 15 June 2018 was her last and the service closed her file. There was no attempt to confirm the level of support JM was actually receiving from her family.

53. It appears, with hindsight, that if DCSSDS had known of the disengagement with Kalwun, proper consideration could have been given to a reassessment.

For this reason counsels assisting suggested a recommendation directed to this issue and it is a matter to which I will return.

The issues

54. A draft issues list was served on the parties prior to the inquest. It outlined the following issues which were anticipated to be the focus of proceedings; Baby Q Issue 1: Can the cause of death be ascertained? What evidence Baby Q supports or detracts from a finding that died as a result of drowning or as a result of suffocation?

34 QCS documents, Exhibit 5, p.156.

35 QCS documents, Exhibit 5, p.159.

36 QCS documents, Exhibit 5, p.158.

Baby Q Issue 2: What did father do on 17 November 2018 to cause her death Baby Q and where was mother at the time?

Baby Q Issue 3: What happened to and her family on 16 November 2018 after Queensland Police were called to the family then sleeping in a park?

Issue 4: What other involvement did Queensland and/or New South Wales Baby Q Police have with parents in the period September – November 2018 and did this involvement prompt reports to relevant child welfare authorities?

Issue 5: What new information did the Queensland Department of Child Safety, Youth and Women and/or the New South Wales Department of Communities Baby Q and Justice learn about and her family circumstances in the period September – November 2018?

Baby Q Issue 6: Was information about and any risks posed by her family adequately shared across state boundaries and between Police and child Baby Q welfare authorities? Did state boundaries impact upon the response to and her family?

Baby Q Issue 1: Can the cause of death be ascertained? What evidence Baby Q supports or detracts from a finding that died as a result of drowning or as a result of suffocation?

55. Dr Andrzej Kedziora, Forensic Pathologist, conducted a post-mortem examination. The report later produced recorded the cause of death as “undetermined”.

Baby Q

56. Notwithstanding this, much of the evidence points to having died as a result of drowning when she was thrown into the Tweed River. This evidence Baby Q does not however exclude the possibility that that suffocated in the period leading up to the moment when she was thrown into the river.

57. Dr Kedziora emphasised that certain “positive” findings are typically seen in cases where someone dies as a result of drowning. Such findings “are nonspecific,” that is, they can be caused by a number of pathological processes or terminal events other than drowning. Nevertheless, Dr Kedziora states that “if

the set is complete and seen in the context of appropriate circumstances and history, they can be regarded as confirmation of drowning”.37 Baby Q

58. displayed some positive findings typical of death as a result of drowning including: Baby Q a) “Washer woman’s hands” observed on hands and to a lesser degree, on her feet.38 b) A report of foamy fluid in the airways also recorded in a police photo from the scene. This was of uncertain relevance because Dr Kedziora could not say where the foamy fluid originated from and the Ambulance Service “did not mention froth coming out of the child’s mouth or nose during resuscitation.39 He also referred to the fact that frothy fluid in the airways can be caused by cardiogenic pulmonary oedema.40 c) Bilateral pleural effusions in a greater amount than the small amount of physiological fluid that is typically present to lubricate the lung surfaces. The amount was also greater than would be expected as a result of early decomposition. The volume of effusions recorded was considered supportive of drowning.41 d) Magnesium was present in pleural and pericardial effusions but its significance was uncertain. Whilst the presence of magnesium was confirmed, “testing for magnesium is not a standard diagnostic method and passive transfer of the electrolyte after death cannot be entirely excluded.”42 e) Foreign debris (sand and possibly silt) was observed in the airways but its significance was uncertain. Grains of sand in the airways or lung tissue could be “introduced via active respiratory movements during drowning or passively, when the deceased is being washed on a sandy beach by waves tumbling and rolling the body, compressing the chest and abdomen, and filling the mouth and nose with water containing suspended sand particles.

37 Autopsy report, Exhibit 1, Tab 2, p.17.

38 Autopsy report, Exhibit 1, Tab 2, p.5 and 17.

39 Autopsy report, Exhibit 1, Tab 2, p. 17.

40 Supplementary autopsy, Exhibit 1, Tab 3, p.42.

41 Autopsy report, Exhibit 1, Tab 2, p.18.

42 Autopsy report, Exhibit 1, Tab 2, p.18.

The deeper in the body the sand particles are found, the more probable it is that they have been introduced during drowning…passive transfer of debris into the peripheral airways and alveoli cannot be entirely excluded.”43

59. In terms of “positive” findings typically seen in drowning deaths but absent in Baby Q case, Dr Kedziora placed some weight on the absence of emphysema Baby Q aquosum or hyperinflated oedematous lungs. Whilst lungs were mottled, congested and slightly oedematous they were not conspicuously hyperexpanded.

60. Dr Kedziora was later provided with additional information from NSWPF RB including the evidence of by-standers who witnessed throw something into the river on the evening of 17 November 2018.

61. In light of this additional information, Dr Kedziora referred to an alternative Baby Q hypothesis that may have been smothered by her father prior to being thrown into the river. Dr Kedziora placed some weight upon the fact that eyewitnesses did not report seeing the objects that were thrown into the river as Baby Q moving, in circumstances where one might have expected would have struggled briefly if she were still alive at that point.44

62. Further, Dr Kedziora noted the evidence from by-standers that “the father carried the child covered by a blanket in front of his body while he walked towards the river. The child may have been smothered during that time.”45 Baby Q

63. did not have petechial haemorrhages in the head region which might be present if she had died as a result of smothering, but Dr Kedziora noted that their absence did not rule out smothering.46

64. In conclusion, Dr Kedziora did not rule out drowning as a possible cause of death. Many of his findings are consistent with that eventuality. However, he remained of the view that the cause of death was undetermined.

43 Autopsy report, Exhibit 1, Tab 2, p.18.

44 Supplementary autopsy, Exhibit 1, Tab 3, p.42.

45 Supplementary autopsy, Exhibit 1, Tab 3, p.42.

46 Supplementary autopsy, Exhibit 1, Tab 3, p.42.

65. Having considered all the available evidence I accept counsels assisting’s submission that the cause of death should be recorded as unascertained or undetermined. Having said that I note Justice Wilson’s analysis in R v RB [2020] NSWSC 1552.47 Her Honour states that while the precise mechanism of death Baby Q remained unclear, death was caused by her father “either by drowning (that being the most likely mechanism) or by suffocation when [he] held her in a blanket pressed against him.” A coronial finding pursuant to section 81 of the Coroners Act 2009 (NSW), is usually taken to refer to the precise medical cause of death. In my view recording the cause of death as unascertained or undetermined is appropriate on the evidence before me and is consistent with the approach taken in the Supreme Court.

Baby Q Issue 2: What did father do on 17 November 2018 to cause her death Baby Q and where was mother at the time?

66. At 9:32am (AEDT) on 17 November 2018, CCTV footage records the family boarding a bus at Kingscliff, arriving at Tweed Heads at 10:52am. They spent the day at the Chris Cunningham Park and Jack Evans Boat harbour.48

67. About 2:30pm (AEDT), Kirsty Davis, a homeless woman, was approached in Chris Cunningham Park by the family, and there was a discussion about giving Baby Q RB Baby Q to Ms Davis. asked Ms Davis to take permanently, and

JM JM he persuaded to hand her to her. According to Ms Davis, Baby Q was crying and did not want to give away, but was eventually persuaded to hand her over. Shortly afterwards, Ms Davis followed the family and returned Baby Q to them and saying that she could not look after the baby when she lived on the streets. About an hour later, the family saw Ms David again, and this time JM tried to give Baby Q to her, but she refused.49

68. During the late afternoon/early evening a large storm accompanied by heavy rain impacted the Tweed Heads area and the family took refuge under a multilevel car park located at the Tweed Mall adjacent to Chris Cunningham Park.

47 R v RB [2020] NSWSC 1552, Exhibit 1, Tab 8 p.228 at [50].

48 Lovell, Exhibit 1, Tab 6, p.85 at [84]-[85].

49 Lovell, Exhibit 1, Tab 6, p.85 at [84]-[85].

69. Between 6:34pm and 6:37pm (AEDT), CCTV footage records the family at JM LB Baby Q Tweed Mall. was carrying and was in a shopping trolley.

70. Around this time, a witness, Emily Gregory reported seeing the family in the car RB Baby Q park near the Bay Street entrance. Ms Gregory observed holding to his chest with a red and black blanket wrapped over her. She observed RB Baby Q JM LB who was still holding walk away from and down JM a ramp leading to Bay Street. CCTV footage confirms that the and LB remained in the car park.50

71. At 6:47 (AEDT), another witness, Paul Thompson, observed a male matching RB description walk along the Southern footpath of Bay Street. He said the male had a blanket wrapped around his body. The male walked towards the river and climbed over the rocks (shoreline) moving close to the water. He threw an “object” into the river, and then moved back to the grass next to the river and fell onto his knees before lying flat on his stomach. He moved his hands to the side of his head and laid in this position for at least 10 minutes.51 At least three other witnesses who reside near the Tweed River similarly observed a male lying on his stomach next to the riverbank in the pouring rain for a period of time.52 53

72. In particular, Joanne Newman and John Waterhouse reported seeing a male lying on the ground next to the river, and item(s) floating in the river. Ms Newman described seeing two separate items, “One was white and one was black. The white item looked like a t-shirt or a small towel, it was floating just under the surface.. about the same size as a tea towel or nappy… The black item was rounded on top and seemed to float on top of the water, it was buoyant…”.54 Mr Waterhouse described the object as a “black coloured reasonable sized squarish object in the river. It was a shape more than a blob. I watched the item 50 Lovell, Exhibit 1, Tab 6, p.87at [90].

51 Lovell, Exhibit 1, Tab 6, p.88 at [92].

52 Lovell, Exhibit 1, Tab 6, p.89 at [95].

53 Lovell, Exhibit 1, Tab 6, p.89 at [96].

54 Judgment, Exhibit 1, Tab 8, p.226 at [34].

for about 30 seconds as it bobbed up and down through the rough waters of the river towards the sea on the outgoing tide.”55 RB

73. At about 7:01pm (AEDT), CCTV footage recorded returning to the car Baby Q Baby Q park at Tweed Mall without . is not seen again on CCTV footage.56

74. Two days later, at about 1:25am (AEDT) on 19 December 2018, a witness, Alexander Owen, was walking along the beach at Surfers Paradise and Baby Q discovered body approximately three to four metres above the waterline. Mr Owen contacted emergency services who attended and attempted Baby Q to resuscitate At 1:51am (AEDT), QLD Ambulance Service pronounced Baby Q life extinct.57 RB

75. The Supreme Court proceedings resulted in a finding that caused Baby Q death by his deliberate act, although he was at that time labouring under such a defect of reason from a disease of the mind that he did not know what he was doing was wrong in accordance with ordinary standards of right and wrong adopted by reasonable people.58 RB

76. Amongst other things, when alone in his cell after being arrested, was Baby Q recorded as saying “She was a bad disease At least I have done a good deed…and the Lord say that too, I done the right…job done, job done. I killed my own daughter…She was a bad disease…At least I destroyed the most dangerous thing throughout the entire world…She shouldn’t even be called a human being. They are lucky I killed her. She is trouble.”59 RB

77. was later recorded as saying to a cellmate “You know, like when she cries, man, fuckin’ terrible…Terrible. When she cries…even, it drains the mother too, and drained me…it makes us fight…You were only supposed to have one child, not two, so, you, you know…Four o’clock, I walked down to river past the elders, she thought I gave the kid to the elders…no, keep going…so I took off the nappy…threw the black and red blanket, and threw that in, and threw her 55 Lovell, Exhibit 1, Tab 6, p.89 at [95].

56 Lovell, Exhibit 1, Tab 6, p.91 at [97].

57 Lovell, Exhibit 1, Tab 6, p.94 at [102].

58 Judgment, Exhibit 1, Tab 8, p.234, [85].

59 Lovell, Exhibit 1, Tab 6, p.97 at [110].

in…So I, when I threw her in, well, it was raining at first…it rained. It…pouring on top of her, (sounds like) and something just told me throw her in. And I just laid down, hands behind my back…and cried. And just…I felt bad.”60 RB

78. There is clear evidence establishing that was actively psychotic at the Baby Q time he took the steps which ultimately resulted in death. His delusions over many years had incorporated religious and spiritual themes and frequently Baby Q focussed on conflicts between good and evil. It appears was somehow entangled in his active delusions and came to represent an evil force in his world RB Baby Q view. The evidence establishes that was alone at the time he took to the water.

JM

79. There is clear evidence that was also actively unwell at the time of Baby Q death. It should also be remembered that she had been subject to RB violence and coercive control perpetrated by over a number of years.

She made statements that indicated she believed he was “the head of the family” and that she could “not stand over him.”61 There are references to her being “mesmerised” by him and appearing fearful of him. Dr O’Neil raised the

RB JM possibility that and shared a delusion, sometimes referred to as a Folie à deux.

80. Despite her significant mental health issues, including the fact that some of her RB recorded delusions appeared to support the idea that she believed was JM God-like or especially spiritually blessed, appears to have done her best to protect her children. It is poignant to review her initial reluctance and RB Baby Q tears when first attempts to give to a homeless woman during the afternoon of 17 November 2018. Particularly when later that afternoon it is JM Baby Q who tries to get the woman to take One can only wonder if, JM even in her own state of ill-health, herself felt that the potential Baby Q danger to was increasing.

60 Lovell, Exhibit 1, Tab 6, p.98 at [113].

61 QCS documents, Exhibit 5, p.157.

Baby Q Issue 3: What happened to and her family on 16 November 2018 after Queensland Police were called to the family then sleeping in a park?

RB

81. QPS had two interactions with during the day on 16 November 2018.

RB

82. The first interaction was at 11:48am (AEDT) when QPS spoke with and JM at Broadbeach about welfare concerns. QPS holdings record “Street Check. CAD event for welfare check. Nil Issues. POI did not want to speak with police.” The records did not reference either LB or Baby Q62 RB

83. The second interaction was at 7:45pm (AEDT) when QPS located and other homeless people drinking in a park at Broadbeach. QPS Holdings record “Located drunk/drinking in the park near the soccer club. All moved on without an incident”. Neither JM nor the children were referred to in the report.63

84. Later that night Senior Constable Zairis and Constable Dorricott were asked to attend Broadbeach Park after it was reported that two children were left alone in the park.64 At about 12.45am (AEDT) on 17 November 2018 the officers found RB JM LB Baby Q and sleeping on the ground with and in between them.65 The children were only wearing disposable nappies and the family had RB limited food and water. was described as intoxicated and unwilling to JM discuss the family’s situation. said they did not like living in a house because it was “cramped” and declined the officers’ offers of assistance. The officers formed the view that “although the children appeared to be healthy and not malnourished from what we could see, we were concerned the parents were not able to care for the children given the very limited food and basic requirements they had in their possession.”

85. Assistance was sought from Plain Clothes Senior Constable Adrian Bisa and Plain Clothes Senior Constable Chloe Barton from the Gold Coast District Child Protection & Investigation Unit. This was clearly appropriate in all the circumstances.

62 Lovell, Exhibit 1, Tab 6, p. 83 at [78], p.127.

63 Lovell, Exhibit 1, Tab 6, p. 83 at [79].

64 Zairis, Exhibit 1, Tab 12, p. 266 at [5].

65 Zairis, Exhibit 1, Tab 12, p.267 at [7]-[10]; Dorricott, Exhibit 1, Tab 15, p.318.

86. At 1:27am (AEDT), body worn camera footage depicts PC S/C Bisa and PC S/C RB Barton arriving at the scene. In response to the officers informing and JM that it was not acceptable to have a nine month old child living on JM the streets, suggested she might be able to arrange travel to Victoria RB to live with her parents, however objected to this and said it was none of their business. The officers determined that the best course of action was to take the family to a ‘place of safety’. However they did not know of any emergency accommodation that was available to which they could take a family at night. PC S/C Barton told the court “…I don’t know if any resources would have been available [for the family]… other than family, friends, associates… I’m not quite sure what other options we had.”66

87. Although the afterhours DCSSDS hotline is available to QPS officers out of hours, unfortunately it was not used on this occasion.67 PC S/C Barton further told the court that she and PC S/C Bisa did not think that the case met the threshold of calling DCSSDS that night, because other than where they were sleeping they did not have information that the children were being neglected or mistreated.68 JM

88. raised the possibility of staying with Paulette Butterworth in Kingscliff.69 JM was able to provide enough detail for the officers to be persuaded that the family had a connection to Ms Butterworth. Attempts were made to call Ms Butterworth without success.70 Similarly, an attempt to have NSW officers attend the Kingscliff address failed. PC S/C Bisa and PC S/C Barton subsequently went to get car seats so that QPS could take the family to the Ms Butterworth’s address.

89. When they arrived at Ms Butterworth’s address, PC S/C Bisa knocked on her door however there was no response. He then spoke to a neighbour and confirmed that the apartment was where Ms Butterworth lived. After attempts to RB raise Ms Butterworth, entered the unit through an open bathroom 66 TN 19/12/23 p.6:9-11.

67 TN 19/12/23 p. 30.1 68 TN 19/12/23 p.7:37-43.

69 Bisa, Exhibit 1, Tab 10, p.253-257; Barton, Exhibit 1, Tab 11, p.263 at [13].

70 Bisa, Exhibit 1, Tab 10C, p.256.

RB window. located paperwork in the unit, which was addressed to Ms Butterworth. At approximately 4:00am (AEDT) the officers left the family at Ms Butterworth’s residence. In my view this was a significant missed opportunity.

90. Senior Constable Zairis and Constable Dorricott completed a street check entry for the interaction with the family, knowing that the CPIU officers would complete a child harm report.71 While I understand why the first responding officers would leave it to the specialised officers to complete the child harm report, unfortunately this meant that some of the useful information the first responding officers were aware of was lost. While PC S/C Bisa and PC S/C Barton left to get the car seats, the other officers had an opportunity to observe the family closely. From viewing the body worn footage and hearing their conversation, it is clear to me that these officers understood, among other things, that both JM parents had significant mental health issues, that appeared to

RB JM believe was the messiah and that was incapable of caring for the children or herself. They understood the children were in some danger.72

91. Prior to completing his shift, PC S/C Bisa completed a “Report of Suspected Harm – 520 – Report.”73 Such a report needed to be reviewed by a Detective Sergeant prior to being sent to DCSSDS.74

92. The Detective Sergeant available to review such reports only worked Monday to Friday between 9am to 5pm. Therefore, this report did not make its way to DCSSDS until after the death of Baby Q75 Although the afterhours DCSSDS hotline is available to QPS officers out of hours,76 it was not used on this occasion.

93. The family left Pauline Butterworth’s home sometime before 9:30am (AEDT) on 17 November 201877, which was approximately six hours after arriving.

71Dorricott, Exhibit 1, Tab 15, p.320 at [27].

72 Body Worn footage, Exhibit 1, Tab 15B.

73 Bisa, Exhibit 1, Tab 10, pp.259-261.

74 TN 18/12/23, p.72:31-36, p.78:8-19; TN 19/12/23, p.13:5-22.

75 TN 18/12/23, p.72:31-36, p.78:8-19; TN 19/12/23, p.13:5-22.

76 TN 19/12/23, p.30.1.

77 JM Exhibit 1, Tab 102, p.1715-1716.

94. The court heard evidence from PC S/C Bisa and PC S/C Barton regarding their decisions that night. Both said that this was an unusual call out and neither of them had previously been called to attend a similar situation involving a homeless baby or infant. Further, neither of them had been involved in a similar call out in the years since Baby Q death.78 In his evidence, Denzil Clark, A/Detective Chief Superintendent of Crime within the Crime and Intelligence Command of QPS, also stated that he could not recall attending an occurrence involving a “family unit” living rough.

95. The officers said they were focused upon dealing with the immediate problem at hand. The decision was therefore made that the family could not remain in the park overnight, given the risk to the children.79 PC S/C Bisa said that he anticipated that the family would remain in the unit for a few nights, although he conceded that there was nothing to stop the family from leaving again.80

96. QPS and the officers themselves submit that all decisions made on 17 November 2018 in relation to the family were made in good faith and with the welfare of the children as their paramount concern, and that all decisions made were reasonable and informed by the information available to them at the time.81

97. In my view, attending police were clearly motivated to assist the family, but they lacked the resources and skills needed in the situation. I accept that the officers had no knowledge of available supported accommodation where they could take the family unit. Nevertheless, it should have been clear, even on the limited contact they had, that the issue was not a simple issue of “homelessness.”

98. It was appropriate to call for first responding officers to make immediate contact with officers from the Child Protection Investigative Unit (CPIU) and ask them to attend.

99. It is acknowledged that the family were not easy to assist and were reluctant to fully engage with police. However, in my view given the clear parental mental health issues it would have been appropriate for officers of CPIU to take the 78 TN 18/12/23, p. 66:31-35; TN 19/12/23,t p.4:5-12.

79 Bisa, Exhibit 1, Tab 10, p.261; Zairis, Exhibit 1, Tab 12, p.268 at [18].

80 TN 18/12/23, p.78:39-50.

81 DSC Bisa and SC Barton submissions 15/03/24.

further step and contact the afterhours DCSSDS hotline for advice, especially when problems emerged at the nominated accommodation.

RB

100. The decision to allow to enter someone else’s house and to leave the family alone at those premises was flawed. There was a need to engage with child protection workers to assist.

101. The evidence also discloses a clear need for increased emergency supported accommodation.

Issue 4: What other involvement did Queensland and/or New South Wales Baby Q Police have with parents in the period September – November 2018 and did this involvement prompt reports to relevant child welfare authorities?

QLD Police Service RB

102. came to the attention of the QPS for homelessness, intoxication and/or aggression on a least five occasions between September and November 2018 (namely on 5 and 6 September, 7 and 27 October and 16 November 2018).

103. The full history of these interactions can be seen in the chronology attached to these reasons and will not be repeated here, but two examples are noted. On JM 5 September 2018, Bradley Fitzsimmons, a council worker, located and the children living in a tent in the sand dunes. Mr Fitzsimmons told JM that they were unable to camp in the sand dunes and provided information for support services for homeless people. It was apparently agreed that she would leave the beach by Friday (7 September 2018).

JM RB

104. then spoke with who approached Mr Fitzsimmons, threw a RB VB bottle and other items at him while verbally abusing him. next armed himself with a stick and chased Mr Fitzsimmons who activated his body worn camera and locked himself in his car. Mr Fitzsimmons called the police whilst RB JM and the children walked away.82

105. QPS were initially unable to locate the family, but they were later able to identify RB and issue him with a Notice to Appear.83 Neither Mr Fitzsimmons 82 Lovell, Exhibit 1, Tab 6A, p.127-128.

83 Lovell, Exhibit 1, Tab 6, p.71 at [53], 149-150.

(who was not a mandatory reporter) nor QPS made a report to DCSSDS. In my view this was a missed opportunity to provide information to DCSSDS.

RB

106. On 27 October 2018, QPS responded to a report regarding being JM present with other homeless people (including and the children) and RB yelling and swearing at people. was chased across the border into NSW and ultimately informed QPS that he was homeless and living in parks with his partner and two young children. There does not appear to be a corresponding DCSSDS Report.84

107. In his evidence, A/Detective Superintendent Clarke acknowledged that child harm reports ought to have been made on these occasions and he stated that he expected this would occur now having regard to increased police training and understanding about the need to record and identify cumulative harm to children.

108. I note that QPS does not concede that all interactions between the family and QPS in the period September – November 2018 should properly have resulted in a QPS child harm report. I accept that some of the contact between the family and the QPS involved less serious incidents which may not, by themselves, have been likely to prompt an officer to make a report of child harm. The difficulty is when seen together and with the benefit of hindsight they create a picture of ongoing and escalating risk that was not available to any other agency.

109. I accept counsels assisting’s submission that there is sufficient evidence on the two occasions described above to make a finding that QPS missed opportunities to notify DCSSDS of the family being homeless and that the young children were exposed to aggressive, intimidating and intoxicated behaviour RB from NSW Police Force RB

110. and/or the family came to the attention of the NSWPF on eight Baby Q occasions between early October 2018 and death. Again, the full detail of each interaction will not be summarised here. I note the following examples.

84 Lovell, Exhibit 1, Tab 6, p.77-78 at [66], 147.

111. On 3 October 2018 NSWPF were called to bushland near the Tweed River to respond to a male pitching a tent. The male, now known to be RB had a sleeping child with him. Upon being approached by police, RB became extremely agitated, began to aggressively grind his teeth and yelled “This is my land”. Officers made observations of the children (they had fresh nappies and no nappy rash) and then left the area. The officers called for backup as a result of his behaviour, but no corresponding report was made to DCJ.85

112. On 11 October 2018, made a report about the family to the Tweed Heads Police Station and to the DCJ Child Protection Helpline.86 Mr was passing on concerns raised by that a family was regularly attending and trashing the parenting room and using the sinks to wash the children’s clothes.87

113. On 2 November 2018, NSWPF attended a park in Tweed Heads in response to a report regarding a family with a toddler and a baby living out of a black van.88 Upon speaking with JM officers noted that the children ‘appear to be well fed, appeared clean and not showing any signs of not being looked after by their parents’.89 They enquired with JM about sourcing accommodation and she replied that RB does not like handouts from the government. NSWPF created a report identifying that the family did not have housing but that ‘the children’s physical and emotional state appears both children appear fine…’.90 This report was processed at the Police Child Wellbeing Unit [PCWU] and entered into Child Story by Assessment Officer Church on 6 November 2018.91

114. I accept counsels assisting’s submission that the evidence demonstrates that some important information was provided by NSWPF to DCJ during this period.

However, there were also incidences which could be considered to be missed 85 Osborne, Exhibit 1, Tab 38, p.942-943.

86 Exhibit 1, Tab 87, p.1634-1635; DCJ documents, Exhibit 4, p.7.

87 Exhibit 1, Tab 88, p.1639-1640.

88 TN 19/12/23, p.81:11 89 Jennings, Exhibit 1, Tab 33A, p.929-930.

90 Jennings, Exhibit 1, Tab 33A, p.931.

91 Dixon, Exhibit 1, Tab 41, p.954 at [11].

opportunities where the circumstances in which the children were living could have prompted consideration of further contact by DCJ.

115. For example, no child at risk report was made by the NSWPF following the interaction with the family on 3 October 2018. The NSWPF submit that this RB decision should be viewed in context, as did not display any signs of JM aggression to or the children, and the officers did not observe any signs that the children were being neglected. The NSWPF further submit that it is unsurprising that no report was made to DCSSDS, particularly given this was the first interaction between NSWPF officers and the family.92

116. The evidence reflects the fact that while both NSWPF and QPS provided some information to the relevant child protection agencies, there were also missed opportunities to provide information which could have alerted the relevant child protection agencies to the fact that there were homeless children who may be in need of support.

117. Unfortunately, with homelessness can come the risk that children are not seen by mandatory reporters such as doctors, teachers, social workers and childcare workers. If a family is also transient and socially isolated the risks are increased.

It is telling that records indicate that on a number of occasions it was strangers or members of the public who contacted police to voice their concerns. In my view, it takes very significant concern to trigger a notification of this sort. While police are not expected to be child protection experts, when they receive this kind of information or come across families with young children who appear to be homeless but antagonistic to the idea of support, that information must be passed on to the experts so that it can be properly reviewed. As counsels assisting submits, evidence of neglect might only emerge incrementally and unless there is a full picture, there can be no effective assessment of risk.

118. Information sharing of all sorts was an important theme running through this inquest. In recommendations I address the need for child protection agencies to have as much information as possible to ground their assessment and decision making processes.

92 NSWPF submissions 15/03/24.

Issue 5: What new information did the Queensland DCSSDS and/or the New Baby Q South Wales DCJ learn about and her family circumstances in the period September – November 2018

DCSSDS

119. At about 8:30pm (AEDT) on 28 August 2018, QPS were called to the apartment on Old Burleigh Road after neighbours contacted them regarding an RB ongoing problem with being intoxicated and abusing neighbours while RB making a large amount of noise. was found a short time later at the beach lying in shallow water and was arrested on an outstanding warrant.93 JM

120. Police spoke to and observed the children, who appeared well.

JM RB According to QPS records, said that was intoxicated and had a right to be. She said he had been drinking, returned home and began yelling and banging on doors.

121. QPS made a notification of suspected harm to a child which said “concerns for their mental health are present. They were not upset in an environment where neighbours could hear the noise from the other end of the unit complex.”94

122. This notification was reviewed by the Gold Coast District Suspected Child Abuse and Neglect (‘SCAN’) Team representative which led to a notification on 30 August 2018 to the South East Regional Intake Service of DCSSDS.95

123. The subsequent Child Concern Report record that resulted from this assessment incorporated extracts from earlier reports in sections called “Most Recent Child Protection History”96 and “Prior child protection history.”97 “Prior child protection history” noted “Both parents were identified to have mental health issues”98 and “two 24 hour notifications recorded within 12 months of each other; both relating to the families lack of stable accommodation and living 93 Lovell, Exhibit 1, Tab 6, p.82 at [73].

94 Lovell, Exhibit 1, Tab 6, p.82 at [73].

95 QCS documents, Exhibit 5, p.184.

96 QCS documents, Exhibit 5, p.186.

97 QCS documents, Exhibit 5, p.186.

98 QCS documents, Exhibit 5, p.186.

in care; and worries about the father’s alcohol abuse issues.”99 When considering the next steps, DCSSDS took into account various factors, including but not limited to, that there was “no information provided to indicate that the children were upset by their exposure or that they were harmed as a direct result of their exposure”.100

124. I accept counsels assisting’s submission that DCSSDS’s assessment was inadequate and that it failed to adequately analyse the information provided and available at that point. This was appropriately recognised in the Queensland Child Death Review Panel’s Panel 75 report, which stated, “There was no understanding that there were very concerning patterns of parental behaviour including incidents of domestic and family violence and parental mental health issues that contributed to frequent periods of homelessness and ongoing risk of emotional harm and neglect for the children”101 There was a lack of recognition RB of the effect of alcohol use and inadequate analysis of what was actually behind the family’s homelessness.

RB

125. The analysis of the children’s reaction to aggression was particularly problematic. Dr O’Neill observed ongoing exposure to trauma and violence may desensitise children and that “quietness” in these circumstances can be indicative of a need for increased curiosity. It was a point also noted in the Panel 75 Report.102

126. In any event, Ms Ryan conceded that the DCSSDS response to the report of 28 August 2018 was inadequate. She conceded more work should have been done at this point.103 I accept her view.

127. The job of a caseworker is difficult and it may be that DCSSDS workers would benefit by having access to specialised psychologists in circumstances such as have been described. It is an issue to which I will return.

99 QCS documents, Exhibit 5, p.187.

100 QCS documents, Exhibit 5, p.130-131.

101 Panel 75 Report, Exhibit 1, Tab 44, p.1010.

102 Panel 75 Report, Exhibit 1, Tab 44, p.1016.

103 TN 20/12/23, p 20-23:34-44.

DCJ

128. DCJ’s involvement with the family occurred at a later stage and was limited to three Child Protection Helpline notifications, only one of which was screened as meeting the threshold of risk of significant harm and one home visit.

129. As outlined at paragraph [112], on 11 October 2018 at 8:19pm, made a report to the DCJ Child Protection Helpline, stating that a young mother and two children were living in a park behind the mall and “trashing” the parenting room.104 He said he had called local Police to ask them to do a welfare check on the family.

130. The Helpline SR Pilot caseworker contacted the Tweed Heads Police, who confirmed that an officer had visited the park earlier that evening but was unable to locate the family. The Helpline notification also indicated that the children had been wearing wet clothing for three days and the Helpline Caseworker requested a welfare check. The Helpline Caseworker contacted Tweed Heads police three times that night regarding the outcome of the welfare check.

131. The DCJ Helpline After Hours Team screened the report as ‘Unknown family’ at Risk of Significant Harm and referred it to Tweed Heads CSC recommending a less than 24-hour response.105

132. On 12 October 2018, a DCJ Caseworker, Tweed Heads CSC allocated the report for further information gathering. However no further work was undertaken in response apparently due to a lack of available resources at the CSC on Friday, 12 October 2018 and Monday, 15 October 2018.106

133. I accept that this was a busy period for the Tweed Heads CSC team and specifically for the DCJ Caseworker.107 I have considerable sympathy for workers placed in this position, but the evidence clearly indicates a systemic staffing issue existed at that time if a matter such as this could not be dealt with in a timely matter.

104 Exhibit 1, Tab 87, p.1634-1635; DCJ documents, Exhibit 4, p.7-8.

105 The DCJ Caseworker, Exhibit 1, Tab 55, p.1213-1214; DCJ ICDR, Exhibit 1, Tab 53, p.1183.

106 The DCJ Caseworker, Exhibit 1, Tab 55, p.1214 at [14]-[15].

107 The DCJ Caseworker, Exhibit 1, Tab 55, p.1214 at [14-15]

134. On 16 October 2018 a support worker from non-government organisation, contacted Tweed Heads CSC and spoke directly to the DCJ Caseworker referred to above. The support worker raised concerns about a young mother and her two children who were “sleeping rough” in circumstances where the mother had been overheard to say they were “escaping domestic violence” in Queensland. The worker expressed concern that the mother was mistrusting of services, possibly trying to avoid child protection, and had temporary accommodation which would expire the next day. The DCJ Caseworker asked the worker to place a mandatory report, which she did the next day.108

135. This prompted the DCJ Caseworker to think back to the unnamed family the subject of a report from the previous week. She asked for a request to be made to the Interstate Liaison Team to seek information from DCSSDS about the possibility of prior involvement with the family.109 The resulting information was received from DCSSDS on 17 October 2018110, after the initial visit between JM DCJ and had already occurred.

136. At approximately 3:00pm on 16 October 2018, the DCJ Caseworker and her JM colleague (another DCJ Caseworker) arrived at the Motel where and the children were staying, as funded by Link2Home, for the purpose of conducting a Safety Assessment during a “home visit”.

LB Baby Q

137. Case notes indicate that and were observed to be settled, clean, JM dressed for the weather and that they appeared comfortable with JM who was attentive to them during the visit. provided a background of RB her relationship with and the family’s involvement with DCSSDS. She said that she did not have any mental health issues and there was no violence RB between her and but that they were “on a break”. She said that she and the children would be travelling to Geelong, Victoria once she received her Centrelink payment (the next day) where she intended to stay with her family RB until she “got back on her feet”. She said would likely stay in Tweed JM Heads or return to Queensland. described the previous incident in 108 The DCJ Caseworker, Exhibit 1, Tab 55, p.1214-1215 at [16].

109 The DCJ Caseworker, Exhibit 1, Tab 55, p.1215 at [19], p.1266.

110 The DCJ Caseworker, Exhibit 1, Tab 55, p.1218-1219 at [35].

RB Tweed Heads with as “someone pissed him off and he smashed JM something at Broadbeach”. told caseworkers she had lost her wallet and did not have keycard, pension card or a charger for her phone.111 JM

138. There is no doubt that was frequently able to present well to those in authority. Interestingly, the QPS officers who observed her from a distance RB interacting with on the evening of 17 November 2018 may have obtained a clearer view of her real mental state.

139. Before leaving Murwillumbah to return to Tweed Heads, the caseworkers JM telephoned their manager to talk about their conversation with and their observations of the children. The caseworkers advised the manager that there were no immediate safety concerns or dangers identified during the safety assessment and the children were safe in the mother’s care.112

140. Shortly after the caseworkers left the Motel (possibly only an hour later), Police JM RB were called to evict and from the Motel for “rowdy behaviour”.113 There was no reference to children being present when Police attended. DCJ did not become aware of this development until 18 October 2018114 and the DCJ Caseworker (being the main caseworker assigned to the family at the time, and first referred to at paragraph 132 above) herself asserts that she did not learn of the eviction until sometime on 19 October 2018, after completing her Safety Assessment.115 JM

141. On 17 October 2018, the DCJ Caseworker tried to speak with but there was no answer, so she left a message.116

142. As noted above, information from DCSSDS was received by DCJ on 17 October 2018. This included information about previous episodes of RB homelessness, the fact that was a “heavy drinker and had schizophrenia” and Police records indicating that each parent was known for mental health JM issues. It also referred to having previously been subject of an 111 The DCJ Caseworker, Exhibit 1, Tab 55, pp.1216-1217, 1279-1281.

112 The DCJ Caseworker, Exhibit 1, Tab 55, pp.1216-1217, 1279-1281.

113 DCJ ICDR, Exhibit 1, Tab 53, p.1192-1193.

114 DCJ ICDR, Exhibit 1, Tab 53, p.1192-1193; The DCJ Caseworker, Exhibit 1, Tab 55, p.1216.

115 TN 18/12/23, p.56:24-28.

116 The DCJ Caseworker, Exhibit 1, Tab 55, p.1218 at [33].

emergency mental health assessment in 2016 when she stopped taking her medication, and details of QPS being called out to the home in August 2018.117

143. The DCJ Helpline assessment was completed as part of the Helpline and Northern NSW District Streamlined Response Pilot. The Helpline Caseworker made further inquiries by speaking to the worker at OTCP, the Tweed Valley Motel and Murwillumbah Police (leading to details of the Police attendance at the Motel).

144. The report was ultimately screened as ‘Non-Risk of Significant Harm’ and referred to Tweed Heads CSC on 18 October 2018.118

145. Meanwhile on 18 October 2018 the DCJ Caseworker had made a further attempt to speak to JM without success.119

146. On 19 October 2018 the DCJ Caseworker completed the Safety Assessment Decision Report based upon what was known as a result of the interview with JM on 16 October 2018 and incorporating reference to some of the information she had obtained after the interview. The DCJ Caseworker determined that the children were ‘safe’.120

147. The DCJ Caseworker and the Tweed Heads CSC had no further contact with the family after the interview on 16 October 2018. The DCJ Caseworker proceeded to conduct a Risk Assessment.

148. This Risk Assessment took into account further information obtained by DCJ JM beyond the information received from in the interview conducted on 16 October 2018.

149. On 31 October 2018 the DCJ Caseworker assessed the children as being at high risk of neglect and moderate risk of abuse.121

150. On 8 November 2018 DCJ sent a notification to the Victorian child protection JM authority providing the address had given as her parents’ home. The 117 The DCJ Caseworker, Exhibit 1, Tab 55, p.1218.

118 DCJ documents, Exhibit 4, p. 99.

119 The DCJ Caseworker, Exhibit 1, Tab 55, p.1219 at [36].

120 The DCJ Caseworker, Exhibit 1, Tab 55F, p.1219 at [37]; p.1291-1294.

121 The DCJ Caseworker, Exhibit 1, Tab 55G, p.1300.

matter was then closed by Tweed Heads CSC as there had been no contact with the family since 16 October 2018.122

151. I am critical of the decision to close the file at this point. There was clear evidence that the family were transient and insufficient attempts to find them were undertaken at this point. As the Internal Child Death Review Report noted there were opportunities for caseworkers to have engaged the local service JM system to keep an eye out for the family, when could not be reached.

There is no evidence that these kinds of strategies were attempted.

152. The Victorian child protection authority ultimately closed the case on the basis LB Baby Q that neither nor were living in Victoria. DCJ only became aware of this plan in Victoria on or around 17 November 2018.123 DCJ’s Safety Assessment and Risk Assessment JM

153. It appears that during her interview with DCJ on 16 October 2018, avoided important issues. For example, she said: a) She did not have any mental health issues124; b) Alcohol or substance abuse was not an issue for the family125; and c) She had the capacity to maintain stable housing in the medium to longterm126.

154. Much of what is now known about the family history was not known to the DCJ Caseworker at the time of her interview. Even accepting this, the Internal Child Death Review Report, the evidence of Simone Czech, Deputy Secretary, and the evidence of the DCJ Caseworker herself confirms that there were a number JM of things that should have prompted further discussion with at the time.

155. In particular, the Internal Child Death Review Report identified that: 122 Czech, Exhibit 1, Tab 56, p.1325-1326.

123 The DCJ Caseworker, Exhibit 1, Tab 55E, p.1270.

124 The DCJ Caseworker, Exhibit 1, Tab 55, p.1221 at [48].

125 The DCJ Caseworker, Exhibit 1, Tab 55, p.1221.

126 The DCJ Caseworker, Exhibit 1, Tab 55, p.1221.

The context of the family’s circumstances at the time needed caseworkers to think beyond that day in the motel. After experiencing weeks of JM Baby Q LB homelessness, and were living in temporary motel accommodation that expired the next morning. More attention should have JM been given to what plans were when the temporary accommodation ended.

… There were a number of opportunities for the caseworkers to have been JM more inquisitive about the information provided, and to have explored more deeply her family’s experience and how this influenced the children’s safety and wellbeing for example…very early in the meeting

JM RB said that was not violent toward her and she explained RB absence by telling caseworkers she and he were ‘on a break’.

JM Regrettably there was no further exploration with about why the break was necessary, whether it was permanent or temporary…Towards

JM RB the end of the meeting said would ‘be back later’ to help her with things. This information should have prompted further exploration

JM RB with about what this meant; was staying with them at the motel or elsewhere? If he was staying at the motel, it may have provided an opportunity to include him as part of the safety assessment.127

156. I accept the opinions expressed in that report and agree that further curiosity was called for at this time.

157. By the time the Safety Assessment Decision Report was completed on 19 October 2018, the DCJ Caseworker had additional information from DCSSDS and the Helpline which provided further detail around the risk of domestic or family violence. However, even this did not prompt the type of curiosity which was called for.

158. The Safety Assessment document (which was later incorporated into the Safety Assessment Decision Report) relevantly stated: 127 DCJ ICDR, Exhibit 1, Tab 53, p.1188-1189.

D9 Domestic/family violence between adults in the household exists and poses an imminent danger of serious physical and/or psychological/emotional harm to the child/young person/unborn child upon birth. Answer: No Narrative: This danger is not identified at this time. This was considered at the time of assessment as it was noted in Housing NSW system (Link 2 Home) that JM stated she was escaping DV from father of the children but did not provide further information. [redacted] to CW [the DCJ Caseworker] on JM 16/10/18 that also reported to [redacted] but again provided no JM further information. denied any violence in the relationship between RB her and She stated they are currently on a break and she is going to move back to Geelong, Victoria and he is going to stay in Tweed Heads or RB return to North QLD where he is from. was not at [sic] present at the hotel…128

159. The DCJ Caseworker apparently understood that her Safety Assessment needed to be limited to the information she had available at the time of the interview at the Motel (although her Safety Assessment Decision Report included reference to information later provided by DCSSDS).129

160. Additionally, the DCJ Caseworker could not recall later having any specific conversation with her Manager regarding the information provided by

DCSSDS.130

161. The evidence of Ms Czech was important in understanding the options open to the DCJ Caseworker once she received the information from DCSSDS and other information after the Motel visit. This information included the following: a) That the family had left stable accommodation on multiple occasions; b) That the family had been homeless intermittently for the last 12 months; RB c) That had a history of schizophrenia and substance abuse; d) That two investigations in QLD by DCSSDS had occurred but neither were substantiated because the parents were willing to engage in external services; 128 The DCJ Caseworker, Exhibit 1, Tab 55F, p.1289 and 1294.

129 TN 18/12/23, p.48: 4-6; p.50:20-50; p.54:7-30.

130 TN 18/12/23, p.52: 7-24.

RB e) That had another child who was subject to long term guardianship order; RB f) That had been the subject of an involuntary treatment order but it was not currently known if he was being treated; RB g) That had a criminal history and a history of being reluctant to JM engage with services; and that mental health was also of concern given (so it was said) a diagnosis of schizophrenia or a delusional disorder and that she had been subject to an EEA.131

162. As Ms Czech observed: On 19 October 2018 the caseworker completed her written safety assessment which reflected the observations and findings made at the home visit on 16 October 2018. The information about the family which was provided to DCJ after that visit was not considered in any depth. In my view there was an opportunity for DCJ to review the children’s safety in light of the further information received. With the benefit of hindsight, the further information ought to have led DCJ to review the children’s safety and to consider whether further enquiries needed to be made about the family.132

163. The fact that new information did not trigger a review or re-assessment was an issue which caused me considerable concern and is one that counsels assisting considered in draft recommendations. Ms Czech provided a further statement after giving evidence in December 2023 which touched on this and other issues. In this statement of 13 February 2024 Ms Czech confirmed that current policy makes clear that if further information becomes available, the caseworker should prepare a 'review Safety Assessment’. It is an issue to which I will return.

Information received by DCJ after the Safety Assessment Decision Report was completed

164. DCJ received further information relevant to the whereabouts of the children after the DCJ Caseworker completed her Safety Assessment Decision Report 131 DCJ documents, Exhibit 4, p.69-75.

132 Czech, Exhibit 1, Tab 56, p.1325 at [55].

on 19 October 2018. This information was not received by the DCJ Caseworker or Tweed Heads CSC.

165. On 1 November 2018 Senior Constable Chayne Foster of NSWPF pulled over RB JM a black van being driven by with and the children unrestrained in the back.133 Concerned about what he saw SC Foster made a report which was verified by his supervisor and referred to DCJ on 5 November 2018.

166. The e-Report raised concerns for Neglect – physical shelter/environment. The narrative included: Father is alcohol dependent. Children located in back of van on a bed. Not in a seat and not secured by a seatbelt. The father has extensive history with Police in both NSW and QLD where alcohol is a major factor to him coming under notice…The child was dirty in appearance and clothes dishevelled. Child is living with father and mother in a van where there is no apparent sufficient food or shelter. Not covered with appropriate clothing.134

167. The e-Report was initially overlooked at the Helpline and therefore not Baby Q actioned. It was not then noticed until 17 November 2018, the day died.135

168. This oversight was attributed to a backlog of 1560 contact records being processed through the Helpline’s e-Reporting portal.136 This indicates a significant resourcing problem which directly impacted on the safety of children.

169. The e-Report was belatedly referred to the Helpline Streamline Response Pilot Program for Northern NSW where it was first screened as Risk of Significant Harm but later rescreened as non-ROSH after further inquiries were made.137

170. In the events that transpired the decision to rescreen the e-Report as nonBaby Q ROSH did not actually affect the outcome for because of the delay in screening the e-Report in the first place.

133 Foster, Exhibit 1, Tab 30E, p.913-916.

134 Foster, Exhibit 1, Tab 30E, p.915.

135 DCJ ICDR, Exhibit 1, Tab 53, p.1198.

136 Czech, Exhibit 1, Tab 56, p.1326 at [61].

137 Czech, Exhibit 1, Tab 56, p.1326-1327.

171. The reasons behind the decision to rescreen the e-Report as non-ROSH though, again highlight the difficulty involved in getting child protection caseworkers to recognise an accumulation of factors pointing to risk of neglect.

172. As summarised in the Internal Child Death Review Report: The decision to close this report at the Helpline was worrying because it did not adequately consider all of the information available to the SR Pilot team. While the SR Pilot team spoken to for this review said they considered all the information available to them before deciding to close the report at the Helpline, it remains unclear why the findings of the safety assessment (dated 16 October

2018. were preferenced (to support the decision to close the matter) over more recent and relevant information…that suggested the children were unsafe and at high risk (in their parents care).

173. Ms Czech has since told the Court that today, all reports made to the Helpline, whether screened as meeting ROSH or non-ROSH, are available on the subject person’s ChildStory timeline.138 Presumably a Caseworker working with the family would have cause to look at the Child Story timeline from time to time and notice any new reports, even if screened as non-ROSH.

Information otherwise entered into ChildStory after the Safety Assessment Decision Report was completed

174. On 2 November 2018 two NSWPF Officers met the family after being called to attend a park in Tweed Heads. This is outlined above at [113].

175. On 6 November 2018 Police then created a Community Service e-Report which was triaged by the Police Child Welfare Unit (‘PCWU’). The PCWU ascertained that Tweed Heads CSC were, in the words of Police, case managing the family.139

176. The PCWU Assessing Officer entered a “Short Description” into ChildStory Baby Q LB that read “Passer-by has reported concerns (9 months) and (1) were unsupervised and family living in a van. Police attended where family advised 138 Czech, Exhibit 13, p.8 at [28].

139 Dixon, Exhibit 11, p.5 at [21].

repairs being done on van and they will soon be moving off to Victoria. Open with Tweed Heads CSC.140

177. Unfortunately, Tweed Heads CSC were not alerted to look for the “Short Description” that had been entered into ChildStory and thus missed knowing this further piece of information.

178. The 2013 Child Wellbeing Unit Operating Guidelines are annexed to Exhibit

13. Section 4.6 provided: In instances where there already is an open case plan for the family held by Community Services, the MRG should still be used to assist the CWO to determine if the concerns meet the threshold for suspected ROSH. If the concerns do not meet the threshold, then the CSC…should be contacted and advised of the concerns. It is best practice to encourage mandatory reports to have an open dialogue with the CSC…about the case.141

14. As at November 2018, there was no system in place at NSWPF to give effect to this part of the CWU Operation Guidelines.

15. In 2018, in order for a DCJ user to view the Short Description in ChildStory, Baby Q they would need to view profile, scroll down and select the Engagements tab and then select the CWU tab to view a list of CWU engagements. The Short Description field would then be visible.142 However, it is clear that DCJ caseworkers would need to be advised about the need to search in the Engagements tab, otherwise given the workload of caseworkers, the record is essentially lost in the system.

16. It is an issue highlighted by counsels assisting and one to which I will return.

17. There is little doubt that both DCSSDS and DCJ received relevant information about the family during the period from the end of August up until November

18. Unfortunately it was not given sufficient weight to trigger consideration of a statutory response.

140 Dixon, Exhibit 11, p.5 at [22].

141 Czech, Exhibit 13, p.75.

142 Czech, Exhibit 13, p. 6 at [20].

183. DCSSDS received new information at the end of August 2018. This new information was not adequately assessed against the family’s known history and DCSSDS failed to place sufficient weight on the potential impact of parental mental health on the lives of the children. This was a missed opportunity.

184. While the family were new to DCJ, it is clear that its response was flawed in a number of significant respects. It is difficult to assess what role a lack of resources played, but there was a failure to properly engage with the information provided and a premature decision to close the file.

Baby Q Issue 6: Was information about and any risks posed by her family adequately shared across state boundaries and between Police and child Baby Q welfare authorities? Did state boundaries impact upon the response to and her family?

185. I accept counsels assisting’s submission that the most significant systemic failings occurred within state boundaries, for example: a) Occasions when QPS (for example, on 5 September 2018 and 27 October

2018308. could have made a report to DCSSDS but did not.

b) A failure by DCSSDS to critically analyse information suggesting that the family’s homelessness was a result of multiple complex factors which combined to put the children at risk of neglect and abuse.143 c) A failure by DCJ to conduct a review safety assessment once aware of additional information from DCSSDS and NSWPF after the interview with JM on 16 October 2018 was completed.

d) A failure by DCJ to do further case work once they were unable to contact

JM JM on 18 October 2018, instead assuming had left for Victoria.

e) A failure by NSWPF, when making an entry into ChildStory on 6 November 2018 referring to the children being unsupervised and family living in a van144 to bring this to the attention of Tweed Heads CSC. Had the CSC 143 See for example the assessment from June 2018 within QCS documents, Exhibit 5, p.159.

144 Dixon, Exhibit 11, p.5 at [22].

been made aware of this information this should have alerted the CSC to the fact the family remained in the local area.

f) A 12 day delay in the DCJ Helpline processing the e-Report from NSWPF received on 5 November 2018. This was the report arising from the family being pulled over with the children unrestrained in the black van. As referred to earlier, this report was not actioned by the Helpline until 17 November 2018 and was ultimately closed at the Helpline. If the information had been conveyed to Tweed Heads CSC on or around 5 November 2018 it likewise should have alerted the CSC to the fact the family remained in the local area g) The report of suspected harm created by QPS on 17 November 2018 required the sign off of a Detective Sergeant and therefore the earliest it could have been provided to DCSSDS was sometime after 9am on 19 Baby Q November 2018, after death.

186. In terms of delay in information sharing when it occurred across state borders, the evidence shows that when DCJ made an appropriate and early request for information from DCSSDS on 16 October 2018, that information was provided the next day. I accept that there was no delay by staff in either department.

Nevertheless, receipt of that information from DCSSDS prior to the home visit might have prompted a different response from DCJ, including consideration of whether a safety plan was appropriate while the risk assessment proceeded.145

187. I note that NSWPF submit that the evidence supports a conclusion that Baby Q information about and her family was appropriately shared between NSWPF and QPS.146 I accept that submission.

Baby Q

188. It is clear that no single agency had all the important information about and her family as it was spread across different agencies and was sometime buried among records held.

189. As I have stated, I accept counsels assisting’s submission that the most significant missed opportunities were internal and were not caused by the need to access interstate information. Nevertheless there appear to be opportunities 145 As suggested in the DCJ ICDR, Exhibit 1, Tab 53, p.1188.

146 NSWPF submissions 15/03/24, p. 7.

to expedite information sharing across borders and it is a matter to which I will return.

Baby Q Summary of changes since death Baby Q

190. In the time since death significant changes to child protection and police practice and procedures have taken place. I will refer only to the most significant changes of immediate relevance to these proceedings.

QPS

191. The Court had the benefit of evidence from Denzil Clark, A/Detective Chief Superintendent of Crime within the Crime and Intelligence Command of QPS, outlining reviews by the Independent Commission of Inquiry into Queensland Police Service response to domestic and family violence and the Women’s Safety and Justice Taskforce.

192. A/Detective Chief Superintendent Clark referred to a cultural change in how police respond to occurrences regarding vulnerable people (including children) and family violence. This includes a greater focus on upon trauma informed and cumulative harm responses and shifting away from a “siloed” approach towards a broader “victim centric” response. He stated that police are now trained to not just think about what “is in front of them”. For example, when police attend to execute a drug search warrant, they are taught to also be observant for any domestic violence and/or child harm concerns. To facilitate this QPS now has additional training in domestic and family violence (a further five day course in addition to the two day training currently required).147 I have no doubt the work done by the Independent Commission of Inquiry into Queensland Police Service response to domestic and family violence and the Women’s Safety and Justice Taskforce is driving change in QPS, nevertheless it will be a long process and will require significant cultural change over many years.

193. The court was informed that in January 2020, QPS introduced the Self-Service of Document Retrieval (‘SSoDR’), a State-wide information portal. The portal can provide Queensland criminal history and domestic and family violence information from QPS records and Information Management Exchange 147 TN 19/12/23, p.21:34-42.

(QPRIME) to approved DCSSDS staff. This preliminary information can better inform follow up via s. 159 requests for further information. SSoDR will be superseded by Unify, DCSSDS’s replacement client management system, which is expected to be implemented by mid-2024.148 This appears to be a significant information systems improvement and one that I will return to.

194. The court was also informed about the National Criminal Intelligence System (‘NCIS’), which is the national information exchange between law enforcement agencies, although not all states and territories are involved. According to A/Detective Chief Superintendent Clark, from mid-2023, QPRIME data was made available on NCIS (as well as CoPS information), and QPS officers can now log in and see occurrences from CoPS in NSW, Western Australia and Victoria.149 This is a positive step for law enforcement across state borders. The usefulness of ready access by child protection workers to certain police data across state borders is an issue to which I will return.

195. There was also evidence that local arrangements are now made for providing NSWPF in the Tweed-Byron Police District with access to daily meetings held by QPS. This kind of local information sharing is to be commended.

NSWPF

196. Evidence from NSWPF regarding changes to the approach to understanding and responding to neglect came via statements from Chief Inspector Mark Dixon of the Child Wellbeing Unit, PoliceLink Command and Detective Inspector Brendon Cullen. Detective A/Inspector Gary Sheehan also provided a statement and gave evidence before me.

197. The court was informed that an initiative is being developed within the Tweed Byron Police District in recognition of the amount of homelessness seen in the area, which involves a multi-agency approach between NSWPF, local councils, DCJ, the Ministry of Health and various non-government organisations.

Detective A/Inspector Sheehan told the court that over the last 18 months, these groups have been trying to come up with a pilot project regarding an appropriate 148 TN 19/12/23, p.40:23-35.

149 TN 19/12/23, p. 69:30-35.

approach when Police come across homeless people in the area. He said the focus is less on “policing” and more on assisting these individuals in whatever way is deemed necessary.150 This initiative is commendable and should receive significant support.

198. The court was informed that fortnightly domestic violence safety action meetings are now held in every Police district comprised of Police, DCJ Housing, DCJ Children, Corrective Services, Education, Health and other nongovernment organisations. The concept is to discuss domestic violence matters (including where children are involved) that have occurred the previous fortnight at a roundtable, and every agency has an opportunity to inform each other of what they know, and try to come up with solutions.151 This appears to be another appropriate partial strategy to ensure better information sharing between local agencies.

199. In relation to communication between the Police Well-being Unit and DCJ, the court was informed that consideration was been given to a “work around” for the problem of entries being made into ChildStory by an assessment officer at the Police Well-being Unit without a relevant CSC being alerted. Now, the assessment officer is required, under the Standard Operating Procedures, to send an email to relevant DCJ officers summarising or attaching the relevant information so that DCJ is aware of the entry in the CWU tab within ChildStory.152

200. Ms Czech also confirmed that currently, a ChildStory user who has access to a family’s ChildStory record no longer needs to scroll down the screen in order to review the Engagements tab. However, the Short Description is still not available on the ChildStory timeline, and is only available by taking the steps referred to above, by accessing the CWU tab.153 It is an issue to which I will return.

150 TN 20/12/23, p.63:21-34.

151 TN 19/12/23, p.78:45-50.

152 TN 20/12/23, p.63:21-34.

153 Czech, Exhibit 13, p.6 at [27].

DCSSDS

201. In respect of DCSSDS, the court had the benefit of the Queensland Child Death Case Review Panels, Panel 75 report, a statement from Chief Practitioner Dr Meegan Crawford, and written and oral evidence from Ms Tracey Ryan, Regional Executive Director for the South East Region of DCSSDS. Changes at DCSSDS include the following.

202. The court was informed that currently SSoDR (managed by QPS) exists and Unify will be implemented by mid-2024. Ms Ryan described the expectation that Unify will be more “person-profile centred. So it brings all of the information around the profile of the child – the young person, and organised information in a much… better way… so SSoDR will be captured through that system.”154 Unify will capture Police information as well as information from non-government services, such as if a referral has been accepted or declined.155 This upcoming change to information systems sounds promising.

203. The court was informed that there have been changes within the Child Safety Practice Manual following a review of the Structured Decision Making tools and the introduction of new practice guides. The new guides aim to encourage greater analysis from caseworkers when assessing harm by moving away from the repetitive use of ‘tick a box’ assessment tools and by placing greater emphasis on caseworkers exercising their own professional judgment. As Ms Ryan told the court, this is particularly relevant to how caseworkers assess cumulative harm when there are multiple notifications.156

204. Although not a new initiative, Ms Ryan also referred to the emphasis now given through the Safe and Together initiative upon “a stronger focus on holding perpetrators of domestic and family violence to account, including perpetrator mapping tool and what coercive control may look like”.157 This is particularly RB relevant to the history given about this family of engaging minimally in 154 TN 20/12/23, p. 36:5-11.

155 Crawford, Exhibit 1, Tab 45, p.1049 at [45].

156 TN 20/12/23, p.30:1-20.

157 TN 20/12/23, p.32.

interviews, while the responsibility of keeping the children safe was left to JM

DCJ

205. For DCJ, the court had the benefit of the Internal Child Death Review and the evidence of Ms Simone Czech, Deputy Secretary, Child Protection and Permanency, District Youth Justice Services, DCJ. Ms Czech’s statement referred to a number of initiatives. I do not intend to repeat the detail of her statement, but note the following matters.

206. The court was informed that the Child and Family Secretaries (‘CAFS’) group is developing a national electronic platform, Connect for Safety, to permit child protection workers to see if a child or family is “known” to child protection authorities in other states and territories.158 The platform does not provide all the information that the other authority holds, but quickly alerts caseworkers to the existence of a child protection history interstate. This can prompt a more targeted requests for information through interstate liaison teams159, and teams can refer to urgency to expedite a response if necessary.160

207. A leadership program now exists for casework managers to improve their practice leadership, in recognition of their role in supervising caseworkers. This includes improving “their capability in understanding work that’s on hand, what might be overdue, putting some systems in place to make sure that records… are completed in a timely manner, so that they’re available for people to review and consider as part of the decision-making.161 It should be remembered that the DCJ Caseworker gave evidence that she could not recall speaking to her manager after she received the Queensland information.162 In contrast it was Baby Q Ms Czech’s evidence that for and her family, once further information came in after the safety assessment, there “must have been” a further assessment review performed involving the manager casework. 163 Any 158 Czech, Tab 56, Exhibit 1, p.1330 at [82].

159 TN 20/12/23, p.73:1-4.

160 TN 20/12/23, p.74:40-41.

161 TN 20/12/23, p.74:40-41.

162 TN 18/12/23, p.52:24.

163 TN 20/12/23, p.45:10-23.

initiatives that strengthen practice leadership and supervision of caseworkers is an important reform.

208. The court was informed that improvements have occurred within ChildStory including the timeline feature where a PDF document will be displayed showing every record that exists in relation to the child in chronological order.164 Any improvement which assists a caseworker to see the complete picture of contact with a child or family is important, particularly where neglect may be an issue.

209. The court was informed that greater use of missing persons reports from DCJ to NSWPF has been instituted.165 In circumstances where a family disappear or seem to “fall off the radar”, this development may be useful.

210. The court was informed that a ‘Neglect Practice Kit’ will be released in July 2024.166 This will be a significant resource that can be accessed by all DCJ caseworkers to assist them in identifying the signs and understanding the impact of neglect, including with respect to cumulative harm. In my view this is an important development and one that is likely to have a positive impact.

211. I accept that DCJ have made some significant changes.

The need for recommendations

212. Section 82 of the Coroner Act 2009 (NSW) confers on a coroner the power to make recommendations that he or she may consider necessary or desirable in relation to any matter connected with the death with which the inquest is concerned. It is essential that a coroner keep in mind the limited nature of the evidence that is presented and focusses on the specific lessons that may be learnt from the circumstances of each death.

213. I acknowledge that my task in considering recommendations is reduced given the changes already made. Nevertheless, at the conclusion of proceedings, counsels assisting put forward a number of draft recommendations for consideration. I will deal with each in turn.

164 TN 20/12/23, p.42:41-46.

165 TN 20/12/23, p.48:1-17.

166 Czech, Exhibit [13], p.11 at [36].

To QLD Director-General, Department of Child Safety, Seniors and Disability Services In situations where DCSSDS refer a family to a family well-being service in the course of an Investigation and Assessment, consideration be given to requiring the family well-being service (however described) to inform DCSSDS if the family disengages prematurely from the service and the reason for the disengagement.

JM

214. The recommendation arose from evidence that disengaged from the non-government service Kalwun almost immediately, while at the same time that relationship was relied upon as a protective factor by DCSSDS.

215. In written submissions DCSSDS drew a distinction between procedures where a referral had been made by them and when a family may have some voluntary contact with a non-government service that had not commenced by way of formal referral from DCSSDS.

216. DCSSDS informed the court that current policy already provides that when a family does not engage with a support service after DCSSDS referral or where a family cannot be located the service provider is required to advise the referrer, typically the Child Safety Officer who made the referral. However, DCSSDS conceded that agencies may not always be complying with the requirement and I understand DCSSDS are open to giving the issue further consideration. I intend to make the recommendation as drafted.

That consideration be given to improving access for DCSSDS caseworkers to expert psychological opinion to help them assess risk to children, when working with a family with complex mental health needs.

217. During the evidence, an issue arose in relation to the availability of expert psychologists to caseworkers in DCSSDS. Dr Alison O’Neil was informed in court by Counsel for DCSDDS that there is a “significant shortage” of psychologists in Queensland generally, and it is even more difficult to find psychologists with child protection experience and qualifications. She was informed that this was the case whether the psychologist was employed

internally or externally to DCSSDS. Dr O’Neill accepted that it would be “difficult but not impossible” to find psychologists to fit that role.167

218. In response to that evidence counsels assisting suggested a recommendation aimed at providing caseworkers with more support. I note that, subject to “implementation practicalities”, it was not opposed by DCSSDS.

219. I intend to make the recommendation as drafted.

To the NSW Secretary, Department of Communities and Justice, and the Commissioner of the NSW Police Force That consideration be given to amending ChildStory so that if an Assessment Officer in a Child Wellbeing Unit makes an entry under the CWU tab for a family where there is an open file at a CSC, the CSC is automatically alerted to the entry having been made (for example, recording contact with the family and concerns assessed as non-ROSH).

220. The recommendation arose out of evidence that an important entry made by the CWU was not seen by the relevant CSC. The issue was accepted by the parties and the court was informed that there is now a method which should alert CSC staff to a relevant CWU entry.

221. The court was informed that the current “work around” is that the NSWPF, through an assessment officer will cause an email to be sent to the relevant CSC where there is an open case.168 This email is not generated automatically but requires an assessment officer to take that step.

222. The draft recommendation suggested that consideration be given to a systems amendment that would mean an automatic notification is generated. Counsels assisting emphasise that the utility of an automatic notification is not undermined by the fact that there is a current work around, where the work around is 167 TN 21/12/23, pp.27:43-50; 28:1-17.

168 NSW Police Submissions at [23]-[24].

dependent upon the assessment officer taking the additional step of emailing the relevant CSC and is not infallible.

223. NSWPF support the recommendation indicating that it would ensure that CSC caseworkers would have greater visibility and that it would increase the likelihood that this information would be accessed by caseworkers in a timely fashion.169

224. DCJ opposed the recommendation, setting out several reasons including that the recommendation including that it, a) Is unnecessary,170 b) Would still require a request under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998;171 c) May have significant resourcing consequences;172 d) Raises questions as to who should receive, and the mechanism for the provision of, such an alert;173 e) May result in less direct communication, via the Helpline between CWU and DCJ, and, paradoxically, may also result in DCJ being inundated with too much information.174

225. I have considered the matter carefully and in my view it is appropriate to give further consideration to an automatic notification. Email or other contact can still be made, but the best way to make sure the notification is made is to have it automatically generated as the information is entered. I intend to make the recommendation as drafted.

169 NSW Police Submissions at [26].

170 DCJ Submissions at [75(a)-(c)].

171 DCJ Submissions at [80].

172 DCJ Submissions at [81].

173 DCJ Submissions at [82].

174 DCJ Submissions at [84] and [85].

That consideration be given to trialling an information sharing portal that gives DCJ direct access to limited but relevant information on CoPS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of Part 16A requests. The Queensland Self Service of Document Retrieval and Unify initiatives provide a useful precedent.

226. Throughout the inquest, a consistent theme emerged recognising that timely information sharing is an important aspect of child protection work which should be prioritised and supported. The speed with which information is shared can be crucial in working with families at risk. As has been noted above, the court heard some evidence about the way information is shared between QPS and DCSSDS using the Queensland Self Service of Document Retrieval and Unify initiatives.

227. Counsels assisting put forward a draft recommendation that consideration be given to trialling an information sharing portal that gives DCJ direct access to limited but relevant information on the NSW Police system CoPS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of Part 16A requests, using the Queensland systems as a useful precedent.

228. DCJ did not oppose the recommendation, but noted that it is primarily a matter for NSWPF, who have ownership of the information held on CoPS. DCJ also noted that the recommendation could have significant resourcing implications for both agencies.

229. Counsel for the NSWPF Commissioner indicated in principle support for the recommendation.

230. Having taken all the information into account I intend to make the recommendation as drafted. It appears appropriate that the recommendation goes to both NSWPF and DCJ for discussion.

To the Commissioner of the QLD Police Service, and the Commissioner of the NSW Police Force That a proposal be taken by QPS and NSWPF to the Australian Criminal Intelligence Commission, which oversees the National Criminal Intelligence System to trial an information sharing portal that would permit state and territory child protection authorities to have direct access to limited but relevant information on NCIS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of further lawful requests for information under state or territory law.

231. Counsels assisting explored the idea that it would benefit state and territory child protection authorities to have direct access to relevant information on NCIS (such as criminal history and domestic and family violence information) to better inform their assessment of risk and the preparation of further lawful requests for information under state or territory law.

232. The recommendation was not opposed by the QPS in principle. However, in noting it is directed towards the respective Commissioners of QPS and NSWPF, QPS suggested that the recommendation should properly be directed to the Australian Criminal Intelligence Commission (ACIC). It appears that the Acting Commissioner of QPS would accept “taking the proposal” to the NCIS, however noted that it would be a matter for ACIC to decide upon, given that body is responsible for priorities and expenditures of NCIS.

233. I note the Commissioner of NSWPF indicated support for the recommendation.

234. I intend to make the recommendation and have it directed to the respective Commissioners of QPS and NSWPF. However, noting QPS’ submission, I have included specific reference to the proposal being taken to the ACIC.

To the NSW Secretary, Department of Communities and Justice That DCJ Caseworker training and policy documents explicitly address the need to conduct a further safety assessment, if relevant additional information is received after an initial safety assessment has been completed prior to concluding a Risk Assessment.

235. Since the inquest was held, DCJ have served further evidence, comprising of a number of policy and training manuals175 regarding review Safety Assessments that are provided to caseworkers. This material clearly outlines when a review Safety Assessment is required.

236. For example, the process of Safety Assessment is described as part of the Structured Decision Making Safety, Risk and Risk Reassessment Manual. That Manual describes the difference between three types of safety assessments: initial, review or closing. A review is described as follows: Review: Any Safety Assessment that is completed because conditions changed while a case is open and the case will remain open.176

237. Further, the Assessment Basics course is a mandatory course for all casework staff, which has online e-learn components and in-person workshops. The online component includes Part 3: Safety Assessment, which explains the three types of assessments: Review Safety Assessment: completed when there is a change in circumstance or change in information known about the family and there is no ROSH report.177

238. Given this evidence, DCJ did not support the recommendation on the basis that it was unnecessary, as there “is already adequate training and policy regarding review safety assessments” (DCJ also provided other training and policy material not summarised above).

175 NSW DCJ bundle of policies and training materials re review safety assessments, Exhibit 15.

176 NSW DCJ bundle of policies and training materials re review safety assessments, Exhibit 15.

177 NSW DCJ bundle of policies and training materials re review safety assessments, Exhibit 15.

239. I accept counsel for DCJ’s submissions on this issue and do not intend to make the recommendation.

Findings

240. The findings I make under section 81(1) of the Coroners Act 2009 (NSW) are: Identity Baby Q

241. The person who died was Date of death

242. She died on 17 November 2018 Place of death

243. She died at Tweed Heads, NSW Cause of death

244. The cause of her death is unascertained Manner of death

245. Baby Q was a child known to child protection authorities. B a b y Q and her family were also known to Police in Queensland and NSW, and her mother and father were known to mental health services in various states. She was killed by her father who was suffering severe psychosis.

Recommendations pursuant to section 82 of the Coroners Act 2009

246. For the reasons stated above I make the following recommendations.

To QLD Director-General, Department of Child Safety, Seniors and Disability Services Recommendation 1: In situations where DCSSDS refer a family to a family wellbeing service in the course of an Investigation and Assessment, consideration be given to requiring the family well-being service (however described) to inform DCSSDS if the family disengages prematurely from the service and the reason for the disengagement.

Recommendation 2: That consideration be given to improving access for DCSSDS caseworkers to expert psychological opinion to help them assess risk to children, when working with a family with complex mental health needs.

To the NSW Secretary, Department of Communities and Justice, and the Commissioner of the NSW Police Force Recommendation 3: That consideration be given to amending ChildStory so that if an Assessment Officer in a Child Wellbeing Unit makes an entry under the CWU tab for a family where there is an open file at a CSC, the CSC is automatically alerted to the entry having been made (for example, recording contact with the family and concerns assessed as non-ROSH).

Recommendation 4: That consideration be given to trialling an information sharing portal that gives DCJ direct access to limited but relevant information on CoPS (such as criminal history Fand domestic and family violence information) to better inform an assessment of risk and the preparation of Part 16A requests. The Queensland Self Service of Document Retrieval and Unify initiatives provide a useful precedent.

To the Commissioner of the QLD Police Service, and the Commissioner of the NSW Police Force Recommendation 5: That a proposal be taken by QPS and NSWPF to the Australian Criminal Intelligence Commission, which oversees the National Criminal Intelligence System to trial an information sharing portal that would permit state and territory child protection authorities to have direct access to limited but relevant information on NCIS (such as criminal history and domestic and family violence information) to better inform an assessment of risk and the preparation of further lawful requests for information under state or territory law.

Conclusion

247. I offer my sincere thanks to counsels assisting Donna Ward SC and Martha Barnett SC, and their instructing solicitors Alexander Jobe and Elizabeth May for their very great assistance in this matter.

248. Both Lizzie Jarrett and Nicolle Lowe, Aboriginal Coronial Information and Support Program workers offered support and information to members of Baby Q family. I thank them also.

249. I further thank Detective Sergeant Daniel Lovell of the Homicide Squad and all other officers involved for their diligent and thorough work in this traumatic matter.

Baby Q Baby Q

250. Finally, I offer my sincere condolences to family. was a beautiful child whose life was cut short. It is out of respect for her life that these proceedings were conducted. It is clear that members of the community who reported her circumstances to police and who offered her family material support could see she needed help. How she fell through the cracks is a matter of considerable concern to me. I note the cooperative manner in which the involved parties approached these proceedings and accept that they were open to Baby Q looking for and understanding the missed opportunities to provide with the help she needed.

251. I close this inquest.

Magistrate Harriet Grahame NSW State Coroner State Coroners Court 18 April 2024

MFI “A” Baby Q Inquest into the death of Chronology of Key Events prepared by Counsel Assisting Deputy State Coroner Grahame

• Glossary of terms included behind chronology

• Queensland child protection authority referred to as Queensland Child Safety (“QCS”) within chronology

• Time markings refer to NSW time

• Where relevant, references to the source documents are followed by references to where Dr O’Neill refers to the incident within her report (Exhibit 1, Tab 115) Number Date/Time (NSW) Event Reference (at p. # of

BOE) Baby Q RB

1. 2 August 1971 father born in Mackay, QLD. He is a Tab 8 – R v RB at p. 223, Torres Strait Islander man. He was raised in Western Australia and [9].

Baby Q Queensland. He is the father of four children; the youngest being Baby Q JM

2. 5 November 1995 mother born in Victoria. She was raised in Tab 105 – Statement of Victoria by her parents, and She has one at p. 1742, younger sibling. [4].

RB Baby Q RB

3. 1996/1997 first child, half-brother, born. The mother of son Tab 21b – ERISP moved to Sydney with his son when his son was still young. transcript at p. 378.

Tab 107 – Statement of at p.

1787, [26], [33].

RB

4. July 2000 first admitted to a psychiatric facility (age 29) and diagnosed with Tab 8 – R v RB at pp.

alcohol induced psychotic disorder. He presented with auditory hallucinations 231-232, [72]-[73].

Number Date/Time (NSW) Event Reference (at p. # of

BOE) and reported suicidal thoughts and homicidal thoughts directed to family Tab 115 – Report of members. Alison O’Neill at p. 1881.

RB

5. 2000-2013 is admitted on at least 35 occasions to psychiatric facilities for psychotic Tab 8 – R v RB at pp.

episodes. He is also subject to numerous Involuntary Treatment Orders. 231-232, [72].

“Throughout these years recurring among the delusions reportedly suffered by Tab 115 – Report of RB were hallucinations of being commanded to kill people and to kill a Alison O’Neill at p. 1881.

baby, delusions concerning black magic, spirits, and elders and, curiously, the singer Britney Spears.” RB Baby Q

6. 9 February 2009 first daughter (second child), half-sister, born. She later Tab 48f – Assessment became subject to a Long-Term Guardianship Order managed by Mackay Outcome Report at p.

CSC. 1101.

Tab 43 – QCS Systems and Practice Review Report at p. 992.

JM

7. 2014/2015 When was 18 or 19 years old, her parents noticed a rapid Tab 105 – Statement of JM deterioration in her mental health. would cry because she felt God at pp.

was going to punish her. During this time she was extremely religious and was 1743, 1745, [16], [29].

of the opinion that she was the mother Mary and she was going to give birth to baby Jesus. Tab 105A – Statement of at pp.

JM Her parents organised for to talk to a priest from the local church to 1755-1756.

JM explain the true meaning of certain bible passages but ended up walking out. According to her father, she appeared to be talking down to Tab 106 – Statement of people and felt that others were beneath her because of this ‘mission’ she had at p.

to fulfill. 1758.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM later went missing from family home, was located by police and began preaching religion to them. She was admitted to various hospital, psychiatric and out-patient facilities following these events.

JM

8. February 2015 first prescribed anti-psychotic medication (Aripiprazole) under the Tab 110 – PBS Patient PBS. Summary at p. 1821.

JM

9. Early February 2016 moved from Victoria to the Gold Coast and allegedly commenced a Tab 102 – Statement of JM double degree in Human Services and Criminology at Griffith University. She at p.

commenced working in a café. 1709, [9].

JM RB RB

10. March 2016 and first met at Surfers Paradise beach. was Tab 102 – Statement of JM homeless at the time. Within about two weeks, an intimate relationship at p.

developed. 1709, [10].

JM abandoned her studies and job and travelled to Mackay with Tab 115 – Report of RB Alison O’Neill at p. 1882.

JM

11. 10 April 2016 parents reported her missing to the QPS and her father travelled Tab 105 – Statement of JM to the Gold Coast to search for her. ( father) reports that he at p. 1746, received concerning texts that she was on a Christian mission and that she [33].

RB was hanging around with a homeless man named “ ” Tab 6 – Statement of JM QPS conducted inquiries and told by Vic Mental Health that has not Daniel Lovell at p. 162.

been formally diagnosed with any mental health issues but had previously suffered from psychotic episodes and was prescribed anti-psychotic Tab 115 – Report of medication. Alison O’Neill at p. 1883.

JM

12. May 2016 re-established contact with her parents and travelled to Geelong, Tab 106 – Statement of Victoria to visit them. at pp.

1759, [15], 1780.

JM Shortly afterwards was admitted on an involuntary basis to the JM acute psychiatric unit at Geelong Hospital (10/05/16-27/05/16). then

Number Date/Time (NSW) Event Reference (at p. # of

BOE) became a voluntary patient on a sub-acute facility, namely Barwon Health’s Tab 115 – Report of Prevention and Recovery Centre (PARC). Alison O’Neill at p. 1883.

Treated for mood disturbance (manic episode) and psychotic symptoms “most likely as part of Bipolar Affective Disorder type 1”. Differential diagnosis includes delusional disorder. Longitudinal assessment needed to confirm diagnosis.

JM

13. found out she was pregnant with her first child while at Barwon. Tab 102 – Statement of JM at p.

JM believes tried to get pregnant so that the child would 1710, [15]-[16].

be born on Christmas Day.

Tab 106 – Statement of at p.

JM

14. August 2016 was discharged from Barwon to a community based mental health Tab 102 – Statement of JM (approx.) treatment service at Belmont. After about a month she commenced living with at p.

RB in a house in South Geelong, Victoria. 1710, [17].

RB

15. 20 September 2016 depot medication had previously been managed via a clinic in Tab 109B – Records Mackay. from Wathaurong Health Service p. 1808-46.

RB first appointment with Dr David Russell (GP) at Wathaurong Health Services, Victoria. History unclear and Dr Russell calls Mackay for details of paliperidone, script later issued and is filled.

RB JM

16. 21 September 2016 , along with , attended upon Dr Russell for depot injection Tab 109B – Records (paliperidone). Dr Russell records “long standing history of paranoid from Wathaurong Health schizophrenia… Did previously have issues with violent behaviour when Service p. 1808-47.

unwell. Ongoing voices who he talks to, but considers these to be good spirits who will encourage him to go on walks or talk to them but do not cause him harm. No paranoia or intention to harm self or others. Used to drink to excess

Number Date/Time (NSW) Event Reference (at p. # of

BOE) but cut back since meeting JM in March. Unable to book in a further appointment as he does not know when he will be back from QLD.” RB

17. 1 November 2016 attends upon Dr Russell for depot injection. Did not have his last depot Tab 109B – Records as planned – never attended in Mackay. from Wathaurong Health Service p. 1808-48.

RB JM

18. 11 November 2016 in Mackay for a court matter. whereabouts are unknown. Tab 109C – Records from Mackay re RB receives a mental state examination by Case Manager (Social Worker) involuntary treatment in Mackay. Does not seem to be a planned appointment or examination: order pp. 1808-70-73.

“RB came into Community Mental Health “to say hello to his CM””.. RB indicates that Geelong is his new home.

RB Recorded that understands that his mental health has been well controlled on depot injections. Case Manager discusses plan to discharge him RB from ITO with psychiatrist. Nothing to suggest is assessed by a psychiatrist prior to decision to discharge.

RB Involuntary Treatment Order was revoked under the Mental Health Act 2000 (QLD). “RB is showing insight into his illness and is committing to remain compliant with medication”…”RB partner is a protective factor for RB . He states ‘JM cooks for me and she’s into health and fitness and now I’m eating vegetables, she drives me to depot appointments and reminds me of when I’m close to being due and she is making me go to the dentist to get me teeth fixed.’” Leads to discharge summary dated 14 November 2016: “RB has limited IQ and has residual symptoms (auditory hallucinations) despite olanzapine treatment. The voices do not generally bother him and he considers them special (“a gift”). It is documented when RB becomes unwell he presents with auditory and visual hallucinations, commanding him to kill people…in the past, repeated Authorities to Return’s have been necessary to ensure RB

Number Date/Time (NSW) Event Reference (at p. # of

BOE) receives his depot medication and attends psychiatrist reviews. On occasions when RB has been sighted in the community whilst overdue for depot injections he has presented agitated and confused therefore staff have been cautious when approaching RB whilst overdue without police assistance.” RB

19. 30 November 2016 attends upon Dr Russell for depot injection back in Victoria. Last depot Tab 109B – Records injection evident from GP records from Wathaurong Health Service. Medicare from Wathaurong Health records do not record any later depot prescriptions/attendances for depot Service p. 1808-49.

injection.

Tab 109 – RB Medicare records at p. 1805.

LB RB

20. 27 December 2016 born in University Hospital, Geelong. was not Tab 106 – Statement of JM present at the hospital at the time of the birth but ( mother) at p.

was present. 1759, [18].

Tab 115 – Report of Alison O’Neill at p. 1883.

21. 11 January 2017 Per GP records from Wathaurong Health Service “noted that RB has not Tab 109B – Records shown up for his depot for 6 weeks. Called on the 2 numbers supplied. Neither from Wathaurong Health number went through. Baby due about this time. Will add to reminder list.” Service p. 1808-49.

No further records available and therefore no information to suggest any RB further contact with JM

22. Mid 2017 (approx.) On one account from , the family travelled from South Geelong, Tab 102 – Statement of JM Victoria to Mackay, QLD. During this time, they were living out of their car. at p.

1711, [22].

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM Baby Q RB

23. found out she was pregnant with . “did not welcome Tab 8 – R v RB at p. 224, the news of JM pregnancy and told her that the unborn child was a [15].

‘bad spirit’. He was intent on the JM having an abortion, but she refused.”

JM LB

24. October 2017 According to , family arrived in Mackay, QLD and she and lived Tab 102 – Statement of RB JM with the father’s sister-in-law, , for a few weeks. regularly at p.

stayed elsewhere. 1712, [25].

JM

25. 27 October 2017 attends Dr Norris (GP) in Brisbane. Tab 110 – Medicare JM records at p. 1818.

26. 1 November 2017 Family self-referred to Kalwun Child, Youth and Family Services (Kalwun) Tab 69 – Kalwun regarding family’s homelessness. Corporation Family Wellbeing Files at p.

Tab 115 – Report of Alison O’Neill at p. 1886.

JM

27. 3 November 2017 Notification made to QCS by providing information that was seven months pregnant and had a 10-month-old son, and among other concerns: the family were living out of a car after relocating from Victoria, the mother left Victoria due to fighting with her parents, the mother and son looked extremely unclean and had not bathed for days, the son had insect bites, scratches and scabbing on his body, the father had schizophrenia and was a Tab 43 – QCS Systems “heavy drinker”, and there were concerns for unborn baby as mother looked and Practice Review physically unwell. Report at pp. 972-973.

Tab 115 – Report of Alison O’Neill at p. 1886.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

28. 6 November 2017 Additional Notified Concerns report received from a second Professional Tab 43 – QCS Systems JM Notifier (not ). Reports, amongst other things, did not have and Practice Review any available funds, crisis accommodation secured for 1 night initially, mother Report at pp. 972-973 recontacted the agency on 3 November and was provided 4 additional night’s accommodation, mother checked out of accommodation next day despite having further 3 night’s accommodation, mother did not attend scheduled appointment and was not returning calls.

JM

29. 9 November 2017 attempted to convince to stay in pre-arranged accommodation but she refused.

Tab 6 – Statement of Daniel Lovell at p. 177.

JM

30. 7 November 2017 – Investigation and Assessment conducted by QCS. was interviewed Exhibit 5 – QLD 23 November 2017 on 7 November 2017 and a Safety Assessment was completed the same day DCSSDS bundle re with an ‘outcome of safe’. reports and assessments at pp. 70-76.

RB was interviewed at the Aboriginal and Torres Strait Islander Family Wellbeing Service on 8 November 2017. Said that he has not taken medication Tab 43 – QCS Systems for one year. Said did not have a problem with alcohol. Said he was on a and Practice Review suspended sentence (charges not disclosed). Report at pp. 973-974.

JM On 17 November 2017 advised QCS that the family was living with Tab 115 – Report of RB cousin (in Mackay) and would be applying for public housing. On 20 Alison O’Neill at pp.

JM November 2017 Housing officers advised that had attended to 1887-1888.

update her housing referral and to be linked with community supports. No concerns were raised. Placed family on priority list for housing.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Assessment and Outcome approved on 22 November 2017 with an outcome of: “Unsubstantiated in relation to LB and unborn Baby. Aboriginal and Torres Strait Islander Family Support Service transferred the case to a relevant service in City2.” (Girudala Indigenous Family Wellbeing Program) RB

31. Mid November 2017 Family living in Slade Point/Mackay with family members – 1 Finch Tab 108 - Statement of Street, Slade Point and 4 Sandpiper Court, Slade Point. at p.

1796, [12]-[15].

Tab 102 – Statement of JM at p.

1712, [25].

Tab 6 – Statement of Daniel Lovell at p. 177.

32. Late 2017/early The family rented and moved into a house in Slade Point, Mackay, QLD (1 Tab 102 – Statement of JM 2018 Rosella Street, Slade Point). at p.

1712, [26].

Tab 105 – Statement of at p. 1749, [52].

JM

33. 27 January 2018 issued with an infringement notice in Mackay for driving with an Tab 6b – Statement of infant greater than 6 months but less than 4 years old unrestrained. Daniel Lovell, chronology of QPS holdings at p.

Baby Q

34. 2 February 2018 born at Mackay Base Hospital, QLD. Tab 102 – Statement of JM at p.

1712, [27].

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 115 – Report of Alison O’Neill at p. 1890.

Baby Q

35. 17 April 2018 seen by Dr Murshed Khan in Slade Point, Mackay. According to Tab 114 – QB Medicare Baby Q Medicare records, this was the only time was seen by a doctor who records at p. 1876.

billed Medicare.

36. 26 April 2018 QPS receive report of a man unconscious on the side of the road. Police Tab 6b – Statement of RB attend and locate walking on roadway. Initially arrested for being drunk Daniel Lovell, chronology in public place but Police discontinue arrest and release him into partner’s of QPS holdings at pp.

JM ) care at 1 Rosella St, Slade Pt. 162, 171.

JM

37. April 2018 (approx..) According to the family moved to Surfers Paradise and rented an Tab 102 – Statement of JM JM apartment. parents paid half of the rent. at p.

1713, [31].

RB

38. 2 May 2018 Police occurrence in Mackay. appeared intoxicated, was incoherent Tab 6b – Statement of and yelling at himself. Police located two knives in a bag concealed in the Daniel Lovell, chronology waistband of his pants. of QPS holdings at pp.

162, 170.

RB

39. 3 May 2018 is arrested for being intoxicated in a public place, in Surfers Paradise. Tab 6b – Statement of Daniel Lovell, chronology of QPS holdings at p.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) RB

40. 4 May 2018 QPS detained at Broadbeach, QLD after locating him acting Tab 6b – Statement of RB aggressively, threatening self-harm and eating dirt and twigs. was Daniel Lovell, chronology heavily intoxicated, and he was taken to Robina Hospital for an emergency of QPS holdings at p.

assessment. 169.

“Initial report from the informant stated that a child had been hurt. Police TUW Tab 6 – Statement of informant who stated that she had not seen any harm to child but was Daniel Lovell at p. 104 concerned with the behaviour of the POI around the child. Police TUW with the [133].

mother of the child who arrived back after police initially attended. She stated that the POI was the father of the child and she was seeking emergency Tab 115 – Report of housing in the coming days through Robina. Nil signs of harm to child. Child Alison O’Neill at pp.

happily playing.” 1891-1892.

RB

41. Details re informant to police being concerned with behaviour around Tab 109A – Robina a child not passed onto Hospital. Hospital records at pp.

1808-11,1808-12, 1808RB Robina Hospital Mental Health Services General Assessment of 29, 1808-39, 1808-43.

• Brought to ED after being picked up by Police in an intoxicated state.

Reported acting bizarrely, aggressive to police and eating dirt, suicidal ideation. No insight into his mental health. Tab 115 – Report of

• On assessment seemed somewhat guarded, but now he is sober he Alison O’Neill at p. 1892.

denies any suicidal ideation and is reporting no psychotic symptoms.

Unable to obtain any collateral information from his partner or sister, so assessment limited by this.

• Historical diagnosis of schizophrenia managed under ITO with paliperidone however on assessment no evidence of psychotic symptoms on review.

• Discussed with Dr Krishnaiah, consultant psychiatrist on call. Discussed no current evidence of thought disorder or psychotic symptoms. Risk appears to be approaching baseline now no longer intoxicated.

• Plan:

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

1. Revoke recommendation – no evidence of an illness that would enable us to keep him under the mental health act.

RB

2. Give contact details to for ACT and offer appointment with community ACT. D/W clinician on overnight will hand over RB to morning team to contact partner. Informed that there are 3 numbers to try.

3. ACT to contact family in the morning for collateral and information on mental state and offer support if required.

4. Referral to HHOT [Homeless Health Outreach Team] for ongoing contact.

• Diagnosis: Acute alcohol intoxication, no evidence of psychotic symptoms on horizontal assessment.

• “Reports has 2 children but no contact with them CIMHA reports more children but limited or no contact with them.” RB

42. 5 May 2018 again detained by QPS at Broadbeach, QLD for being highly Tab 6(b) – Statement of JM intoxicated. Transported to Southport watch house to “sober up”. Daniel Lovell, and children were “transported to Miami One where she stated she was chronology of QPS staying with a friend. Children were happy, had milk and nappies and seemed holdings at pp. 161, 168.

in good health.” Tab 115 – Report of Alison O’Neill at p. 1893.

JM Nurse, Kristi Gardner, from Robina Acute Care Team, tries to call Tab 109A – Records RB and on numbers provided to ED. Leaves messages for a return call. No from Robina Hospital evidence to suggest calls ever returned. (extracts) p. 1808-14.

RB

43. 7 May 2018 Alison Stinton from Robina Acute Care Team calls HHOT re , and Tab 109A – Records HHOT indicates that he is well known to them. Letter is also sent to Aboriginal from Robina Hospital & Islander Community Health, MacKay. (extracts) pp. 1808-11808-17.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) RB

44. 10 May 2018 arrested for public nuisance and possession of weapons in Surfers Tab 6b – Statement of Paradise. He is found with a credit card knife inside a small pouch inside his Daniel Lovell, chronology pocket. of QPS holdings at pp.

161, 167-168.

RB

45. 11 May 2018 After charge: public nuisance, referred for assessment by a Court Tab 109A – Records RB Liaison Clinician. offered an assessment for mental health needs from Robina Hospital however declined to participate and no indication of need to conduct on an (extracts) p. 1808-22.

involuntary basis.

RB

46. 14 May 2018 failed to appear in Mackay to have his identifying particulars taken for Tab 6b – Statement of resist arrest, incite, hinder, obstruct police. Daniel Lovell, chronology of QPS holdings at p.

161, 166.

RB Baby Q LB

47. 27 May 2018 The QPS located and “sleeping rough” in a park at Surfers Tab 6b – Statement of Paradise. The children were noted to be “clean, appeared well fed and the Daniel Lovell, chronology father had supplies of nappies and milk formula for the infants.” The QPS of QPS holdings at pp.

RB holdings note that the had a history of mental illness and extensive 164-166.

RB criminal history. Officers attempted to locate accommodation for and the children on the Gold Coast but were unsuccessful. Tab 115 – Report of Alison O’Neill at p. 1893.

A ‘Child Harm Referral Report’ was created and disseminated to the Gold Coast Suspected Child Abuse and Neglect (SCAN) Team for review. Tab 29a – QPS Operational and The SCAN Team is a QPS initiative, and its purpose is to “enable a Procedures Manual as at coordinated, multi-agency response to children where statutory intervention is July 2023 at p. 751.

required to assess and meet their protection needs.”

48. Notification made to QCS (by QPS) that children sleeping in a park and both Tab 6b – Statement of parents having historical mental health issues. Daniel Lovell, chronology of QPS holdings at pp.

164-166.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Details include “Police information system records outline issues of both the Exhibit 5 – QLD mother and father having mental health issues and the father’s public DCSSDS bundle re intoxication. The mother is listed in 2016 as requiring an EEA for mental health reports and assessments assessment of her paranoid schizophrenia whereby she was of the belief at that at p. 82.

LB time she was about to give birth to the child of Christ (subject child ). QPS notes outline the mother “went off her medication” at this time.

Tab 43 – QCS Systems JM was contacted by Joseph Leadbetter, Child Safety Officer at QCS. and Practice Review Mr Leadbetter secured and funded accommodation for the family for two nights Report at p. 975.

at a motel.

Tab 46 – Statement of Interviews and assessments followed. Joseph Leadbetter at p.

1060, [8]-[10].

Following a Safety Assessment (children assessed as safe) an “Assessment and Outcome” on 7 June 2018 recorded the matter as “unsubstantiated” as “there is Tab 48f – Statement of no information that either LB or Baby Q has suffered significant harm… RB Elissa Brewer, consumes alcohol outside the home…JM is a parent who is willing and Assessment Outcome able to meet the above identified needs of her children.” Report at p. 1103.

Further details of assessment process referred to below. Tab 115 – Report of Alison O’Neill at pp.

1893-1895.

49. 28 May 2018 QCS Investigation & Assessment commenced, tasked to Greta Weertman, Child Tab 48 – Statement of Safety Officer. Both children sighted at a motel where the family were staying. Elissa Brewer pp. 1067Children appeared clean and appropriately dressed. No concerns were noted 1068, [8a]-[8c].

JM JM about the children’s presentation or interactions with said JM they had found it difficult to secure accommodation. Staff observed Exhibit 5 – QLD with a blood shot eye and bruising which she said she sustained playing football. DCSSDS bundle re

JM RB denied was violent towards her. reports and assessments at p. 145.

RB sister, , was present as a support person during the interview and QCS notes state that said, “you’re scared of him (referring to RB

Number Date/Time (NSW) Event Reference (at p. # of

BOE) to which JM replied “RB the head of the family, I can’t stand Tab 43 – QCS Systems over him””. and Practice Review Report at p. 976.

Tab 115 – Report of Alison O’Neill at p. 1896.

50. 29 May 2018 QCS received further information regarding the family from the QPS referred to Tab 6b – Statement of RB in the QPS holdings reference Ql1800966268. Includes reference to Daniel Lovell, chronology extensive criminal history with specific details of relevant matters from 2011- of QPS holdings at p.

2018 and an offer to provide full history on request. 163.

Child Safety Officers Crystal Sandford and Madeline Kelly again visited Tab 48 – Statement of JM LB Baby Q RB JM , and at a motel. not present. agreed Elissa Brewer pp. 1068to work with Aboriginal and Torres Strait Islander Family Wellbeing Service and 1069, [10a]-[10e], 1076.

JM said had accommodation in motel for two nights. observed to have bruising around her eye. Tab 43 – QCS Systems and Practice Review Safety Assessment completed by Greta Weertman. She recorded outcome of Report at p. 976.

‘safe.’ Tab 115 – Report of Rationale: The notified concerns suggested that the following harm indicators Allison O’Neill pp. 1896may be present: harm indicator 4 (Parent contributes to hazardous living 1897.

conditions that pose an immediate threat to the health or safety of child) due to concerns that the family were homeless and living in a situation that was hazardous to the children and did not align with their needs. However after JM LB Baby Q interviewing and sighting and it was assessed that he was not at immediate risk of suffering harm as: JM A. has sourced a 3 month lease and is currently supporting her family in motel accommodation until she can access that; JM B. has reengaged with Kalwun FSS who are supporting her in working with housing to get bond loan;

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM C. has engaged readily with the department and kept services updated about her and the children’s whereabouts; LB Baby Q D. and were sighted to be clean, happy and appeared generally well cared for.

As such a safety decision for the household of SAFE has been determined.

51. 30 May 2018 Ms Weertman received information via a s.159 request from Child Protection Tab 48 – Statement of Advisor and Paediatrician at Gold Coast University Hospital, children not Elissa Brewer p.1070, known to the Gold Coast Health Service, mother had a documented mental [14] and “EB4” p. 1088 health admission on February 2015 with delusional disorder, self-ceased medication on October 2015, was listed as a missing person in Victoria, JM documentation that had left her accommodation and job to live with RB 40 year old or “God” and she was planning to have “God’s baby. Her JM parents reported concerns about having religious delusions.

Father had significant contact with health services across QLD, history of schizophrenia and alcohol dependence.

JM

52. 31 May 2018 advised Ms Weertman that the family was approved for a bond loan Tab 43 – QCS Systems and would be moving into a unit the next day. and Practice Review Report at p. 977.

Tab 48 – Statement of Elissa Brewer p. 1070, [15].

Tab 115 – Report of Alison O’Neill at p. 1900.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

53. 4 June 2018 Ms Weertman and Child Safety Support Officer Kristy Wright conducted an Tab 48 – Statement of unannounced home visit at the apartment where the family was residing. Elissa Brewer p. 1070, RB was not home. Staff said they would need to speak to him, but [16].

JM said it was preferable for this to be done over the phone.

JM advised that her parents were helping with the rent and would be Tab 43 – QCS Systems visiting in a few weeks. and Practice Review Report at p. 977.

Tab 115 – Report of Alison O’Neill at p. 1900.

RB

54. 5 June 2018 advised Ms Weertman via telephone call that the family had Tab 48 – Statement of somewhere to stay. He did not wish to speak any further to Departmental Elissa Brewer p. 1070, JM officers. Passed phone to . Ms Weertman offered support for [17].

RB JM RB alcohol use. stated she did not believe would engage, and that he did not drink at home. She advised that the family had Tab 43 – QCS Systems engaged well with the Aboriginal and Torres Strait Islander Family Wellbeing and Practice Review Service . Report at p. 977.

Tab 115 – Report of Alison O’Neill at p. 1901.

55. 7 June 2018 Kalwun “had discussions with JM regarding referral to DV and supports put Tab 69 – Kalwun into place around RB not taking his medication for schizophrenia.” Corporation Family and Wellbeing Program Files at p. 1552.

56. 5 June 2018-7 June The Assessment was completed on 5 June 2018. It was then approved on 7 Tab 48 – Statement of 2018 June 2018. Elissa Brewer at p. 1071, [18].

Assessment and Outcome: “Unsubstantiated, Child Not in Need of Protection”.

The final risk level of moderate was determined. The form was approved by Tab 43 – QCS Systems Elissa Brewer. and Practice Review Report at p. 977.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 115 – Report of Alison O’Neill at pp.

1902-1903.

57. 12 June 2018 Tanya Blackhall, Intake Gold Coast Officer, Kalwun, indicates that Kalwun Tab 68 - Kalwun does not think that the children are at unacceptable risk due to the protective Corporation Recognised nature of the mother, and agrees with the outcome of the investigation and Entity Program Files pp.

assessment of QCS. 1438-1439.

JM

58. 15 June 2018 Contact between Kalwun and at Cascade Gardens. Kalwun raised Tab 69 – Kalwun RB concerns regarding domestic violence, mental health and alcohol use. Corporation Family JM stated: Wellbeing Program Files

• There was no domestic violence in their relationship. at pp. 1552-1553.

• RB was “going through a bad stage” regarding his mental health due to being homeless and “the situation” but is “much better now and Tab 115 – Report of doesn’t need any supports.”. Alison O’Neill at p. 1906.

• RB was not drinking at that time but was before due to stresses around being homeless.

JM declined any support, and stated she had to support her

RB RB (presumedly a reference to sister ), and who is temporarily staying with them. She said her landlord told her yesterday that she would extend their lease after the three months.

JM agreed to her family’s case being closed, and said she would contact them if she needed any further support. Kalwun records: “This is not a mandatory service and once a family say they want to close we have to respect their decision”. Kalwun closed the case on 19 June 2018.

RB

59. 16 July 2018 appears agitated during a street check with QPS. He calms down and Tab 6b – Statement of goes with his sister Daniel Lovell, chronology of QPS holdings at p.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM

60. August 2018 parents visited the family at their apartment in Surfers Paradise. Tab 105 – Statement of JM They noticed a cigarette burn in the centre of forehead, which she at pp.

RB said she had done herself. appeared to be heavily intoxicated but was 1751-1752, [66] and [72].

friendly and not aggressive.

Tab 115 – Report of Alison O’Neill at p. 1906.

RB

61. 1 August 2018 is found to be intoxicated in a public place by the QPS. Tab 6b – Statement of Daniel Lovell, chronology of QPS holdings at p.

RB

62. 4 August 2018 is found to be intoxicated in a public place and begging at 12:37pm, he Tab 6b – Statement of is placed under arrest. Daniel Lovell , chronology of QPS holdings at p. 156.

63. 28 August 2018 The QPS called to a disturbance at the family’s address, Police met by a Tab 6a – Statement of RB number of other neighbours at front gate, and partner had taken two Daniel Lovell, chronology RB children to beach. When Police arrived at the beach became of QPS holdings, at p.

aggressive before running away into the darkness. Another Police crew located 129.

him short time later laying in shallow water. Arrested on warrant.

Tab 115 – Report of

JM RB RB told police was intoxicated and had a right to be. … Alison O’Neill at p. 1907.

had been out drinking, returning home, began yelling and banging doors…Neighbours have called police with concerns for welfare of the children RB and their own families. Neighbours say this is an ongoing matter where will become intoxicated and abuse neighbours while making a large amount of noise….children appeared well although concerns for their mental health are present. They were not upset in an environment where neighbours could hear the noise from the other end of the unit complex.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

64. 30 August 2018 ‘Child Concern Report’ made to QCS by the QPS in respect of events on 28 Tab 6a – Statement of August 2018. There were: “Serious concerns for the welfare of the children due Daniel Lovell, chronology to father’s erratic behaviour whilst under the influence of alcohol… The mother of QPS holdings, at pp.

appears to have no concerns for her partner’s behaviour in front of the 130-131.

children.” Exhibit 5 – QLD The report was reviewed by QCS, and recorded as a CCR. The CCR noted the DCSSDS bundle re following as matters QCS were ‘worried’ about: reports and assessments

• “exposed to their father's alcohol use, which resulted in erratic and at p. 187.

abusive behaviours”;

• “father ran from police and when located was verbally aggressive Tab 115 – Report of towards them”; Alison O’Neill at pp.

• “children seemed un-phased by their father's actions and seemed to be 1908-1910.

used to the incidences”; and

• “two 24hr notifications recorded within 12 months of each other; both relating to the families lack of stable accommodation and living in cars; and worries about the father's alcohol abuse issues”.

When considering the next steps, QCS took into account:

• “no information provided to indicate that the children were upset by their exposure or that they were harmed as a direct result of their exposure”;

• “no information provided to indicate that JM was under the influence, or was not a parent able to take primary care of the children when RB drank”;

• “family have maintained stable housing since the closure of the IA, and there have been no concerns reported of a similar nature since the IA, indicating an escalation of parental behaviour”.

65. August 2018 (more Throughout August 2018 (more likely September on the information available Tab 88 – Statement of likely September on to the Court) at p.

the information in Tweed Heads, reported seeing a mother and her two children regularly 1638-1640.

available to the attending the parenting room located within the shopping centre.

Court) reported that the family were ‘dirty’ and ‘smelt bad’ and occasionally saw the

Number Date/Time (NSW) Event Reference (at p. # of

BOE) father with them. She stated that the mother would lay blankets on the floor for Tab 87 – Statement of the children to sleep on and used the sink to wash the children’s clothes. On at p.

11 October 2018, reported the situation to 1634, [4].

who notified the NSWPF (Tweed Heads Police Station) and ‘DOCS’ (Family and Community Services) about the family. Tab 6 – Statement of Daniel Lovell at p. 71 [51].

Tab 115 – Report of Alison O’Neill at pp.

1906- 1907.

JM

66. Early September called her mother and told her not to worry about paying the rent on Tab 106 – Statement of 2018 the Broadbeach unit as they had left unit. She did not tell where she at p.

was going. 1760, [24].

The family started living rough on the streets between Northern NSW and Tab 102 – Statement of JM South Eastern Qld. at p.

1713, [35].

Tab 115 – Report of Alison O’Neill at pp.

1910-1911.

67. 5 September 2018 Bradley Fitzsimmons, an employee of the City of Gold Coast Council Tab 30 – Statement of responded to reports of people illegally camping in the sand dunes at Pratten Senior Constable JM Park, Broadbeach. Fitzsimmons located and the children living in a Chayne Foster at p. 882.

tent in the sand dunes.

Tab 6 – Statement of JM Fitzsimmons advised that it was against council regulations for Daniel Lovell at pp. 71 them to camp there and provided her information for homeless support [53], 149.

RB services. Shortly after confronted Fitzsimmons verbally abusing him, throwing a VB bottle at him, and arming himself with a stick.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 115 – Report of RB The Police were contacted but were initially unable to locate Alison O’Neill at p. 1911.

JM or the children.

RB Police were later able to link this matter to and issue him with a Notice Transcript for 19 to Appear. December 2023 at p.

33:31-35.

No report made to QCS.

RB

68. 6 September 2018 The QPS detained at Broadbeach as a result of him being ‘severely Tab 29a – QPrime affected by intoxicating substances’ and ‘barely able to speak’. At the time, history contained within RB was armed with a ‘large metal bar’ which he had concealed under his Report of Suspected jacket. Harm, QPS Report No: QP1802145443 at p.

Tab 6 – Statement of Daniel Lovell at p. 74 [55].

Tab 115 – Report of Alison O’Neill at p. 1912.

69. 7 September 2018 A QCS Case Worker emailed Kalwun with updated referral information for Tab 69 – Kalwun Family Family raising “additional worries” for the family and asked Kalwun to consider Wellbeing Program Files the information as a referral update for their work with the family. Information at p. 1526.

RB included reference to older child subject to long term guardianship order, reported information from Police attendance on 30/08/18 (which in turn Tab 6 – Statement of incorporated most recent child protection history). Daniel Lovell at p. 195.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 115 – Report of Alison O’Neill at p. 1912.

70. 18 September 2018 Kalwun unable to contact or locate family for referral intake as they were Tab 69 – Kalwun homeless at the time. Corporation Family Wellbeing Program Files at p. 1454.

Tab 6 – Statement of Daniel Lovell at p. 179.

Tab 115 – Report of Alison O’Neill at p. 1912.

71. September/ October During this period, a witness by the name of Maxine Johnson, who resided in Tab 96 – Statement of JM RB 2018 the vicinity of Bay Street, Tweed Heads, reported seeing Maxine Johnson at pp.

and the children in the vicinity of her home on approximately 6 occasions. On 1678-1680.

RB one occasion Johnson described as carrying the children in a ‘rough manner’. Tab 6 – Statement of Daniel Lovell at p. 75 [58].

Tab 115 – Alison O’Neill at pp. 1912-1913.

72. October 2018 The family access Fred’s Place in Tweed Heads several times for basic Tab 65a – Statement of services. Alysia Hopkins, case notes at p. 1409.

Tab 6 – Statement of Daniel Lovell at p. 107, [147].

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 115 – Report of Alison O’Neill at p. 1917.

73. 3 October 2018 Constable Danielle Osborne and Senior Constable Cogin (NSWPF) were Tab 38 – Statement of called to bushland near the Tweed River to respond to a male pitching a tent Danielle Osborne at pp.

with a sleeping child, and the male reportedly looking around and acting 942-943.

suspicious.

The officers observed the family living in a tent, with fishing rods and chairs set Tab 115 – Report of RB up. became agitated when officers questioned what they were doing in Alison O’Neill at pp.

the area, grinding his teeth and yelling ‘THIS IS MY LAND’. The officers 1913-1914.

requested back-up due to the father’s agitation, and Senior Constable Andrew Greenup and Senior Constable Barry Carr subsequently attended. The mother Baby Q was changing nappy and the officers noted she did not have nappy rash and there were fresh nappies for her. The officers left the area and returned to other duties.

JM

74. 6 October 2018 called her mother and asked her to immediately book flights to Tab 106 – Statement of LB Baby Q Victoria for her, and Tickets were booked for that evening at p.

JM LB Baby Q however , and never arrived. 1760, [26].

Tab 115 – Report of Alison O’Neill at p. 1915.

75. 7 October 2018 Ms Prouten, a member of the public, calls ‘000’ after observing a male hit bins Tab 80 – Statement of and tables with a stick with aggression, stating that the baby and toddler were Jazmin Prouten at pp.

clothed only in nappies and the mother appeared to be under his control. 1610-1611, [5]-[8].

RB JM Street check for a disturbance by QPS at 6:52pm with and Tab 6b – Statement of LB Baby Q both named. No details on or Daniel Lovell, chronology of QPS holdings at p.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

76. 11 October 2018 Notification to DCJ Child Protection Helpline: at 7:19pm Tab 88 – Statement of made a report to the Helpline, stating he at p.

had received an email stating a young mother and two children were living in a 1638-1640.

park behind the mall and ’trashing’ the parenting room. He said that he had called local police to ask them to do a welfare check on the family. Tab 87 – Statement of pp.

The Helpline SR Pilot caseworker contacted the Tweed Heads Police. At 1634-1635.

9:26pm, police confirmed that an officer had visited the park earlier that evening but was unable to locate the family. The Helpline notification also Tab 55 – Statement of indicated that the children had been wearing wet clothing for three days, the at p.

reporter requested a welfare check. The Helpline Caseworker contacted 1213 [9]- [10].

Tweed Heads police three times that night regarding the outcome of the welfare check. Tab 53 – Internal Death Review at pp. 1182The DCJ Helpline After Hours Team screened the information about ‘Unknown 1183.

Unknown family’ as Risk of Significant Harm, and referred it to Tweed Heads CSC recommending a less than 24-hour response. Tab 115 – Report of Alison O’Neill at pp.

1915-1916.

77. 12 October 2018 Caseworker, Tweed Heads CSC allocated the report for Tab 55 – Statement of further information gathering, however no further work was undertaken in at p.

response due to the absence of identifying information about the family, as well 1214, [14].

as limited resources at the CSC on Friday 12 October 2018 and Monday 15 October 2018. Tab 53 – Internal Death Review at p. 1183-1184.

The CSC allocated one ROSH report for a face to face (safety) assessment on 12 October, and four ROSH reports for face to face (safety) assessments on Tab 115 – Report of 15 October. Alison O’Neill at p. 1917.

78. 15 October 2018 a support worker from Tab 62, Statement of (now known as a community-based organization, at pp.

observed on her lunch break a young woman and an Indigenous man sitting in 1372-1375.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) a set of fire stairs near the entrance of Tweed Mall. The location was known to be frequented by homeless people. She also observed a toddler boy with the couple, sitting in the child section of a front of the trolley.

When she arrived back at the office, she observed the same lady and toddler out the front of the office. She also observed a baby lying in the trolley.

introduced herself as working at and asked if the lady needed any help. The lady said that she had just fled QLD from a DV situation, she didn’t want to talk about it or be supported for it as the Police were involved.

JM She said she needed accommodation. She stated her name was JM invited inside and assisted her in contacting JM Link2Home. subsequently obtained two nights’ accommodation at JM the Tweed River Motel at Murwillumbah. also provided with formula, nappies, food items and some bottles, and offered assistance JM travelling to Murwillumbah, which was declined. and the children left.

asked her colleague, to submit a report to DCJ.

79. 16 October 2018 In the morning, contacted Tweed Heads CSC and spoke to Tab 63 – Statement of JM LB Baby Q to discuss her worries for and According to at pp. 1379recollection, told she could see there were numerous 1380.

reports regarding an unknown lady with two dark children living in a trolley under a tarp in the park close to the Boat Harbour area, Tweed Heads. Tab 55 – Statement of JM asked the condition of the children, whether identified as at p.

having drug and alcohol issues, and about their general well being. 1214, [16]-[21] told her that the three presented happy, well bonded, and that she could not detect any drug and alcohol or mental health issues. asked Tab 53 – Internal Death to place a mandatory report. Review at p. 1184.

recalled the report about the unknown family received five days Tab 115 – Report of earlier. Alison O’Neill at p. 1920.

RB Number Date/Time (NSW) Event Reference (at p. # of

BOE) spoke with a colleague from NSW Housing co-located within Tweed Heads CSC re temporary accommodation offered to family and also completed a Pre-Assessment Consultation with A/Manager Casework.

80. At 2:19pm (AEDT), requested that an email be sent to DCJ’s Tab 55 – Statement of Interstate Liaison Team to request advice from QCS about whether they had at p.

any prior involvement with the family. 1214, [19].

Tab 115 – Report of Alison O’Neill at p. 1920.

81. At approximately 3:00pm (AEDT), and colleague Tab 55 – Statement of JM LB Baby Q arrived at the motel in Murwillumbah where and were at pp.

staying for the purpose of conducting a Safety Assessment. 1216-1217, [22]-[28], 1279-1281.

A Safety Assessment helps practitioners determine the immediate safety needs of the child and if they may safely remain in the home, with or without a safety Tab 56 – Statement of plan in place. Simone Czech at p.

1322, [42].

LB Baby Q and were observed to be settled, clean, dressed for the weather JM and appeared comfortable with who was attentive to them during the Tab 53 – Internal Death

JM RB visit. provided a background of her relationship with and the Review at pp. 1185families’ involvement with QCS. She said that she did not have any mental health 1187.

RB issues and there was no violence between her and , but that they were “on a break”. She said that she and the children would be travelling to Geelong, Victoria once she received her Centrelink payment (the next day) where she Tab 115 – Report of RB intended to stay with her family until she “got back on her feet”. She said Alison O’Neill at p. 1921.

would likely stay in Tweed Heads or return to Queensland.

JM described previous incident in Tweed Heads with father as “someone pissed him off and he smashed something at Broadbeach”.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM told caseworkers she doesn’t have keycard, lost wallet, no pension card and no charger for phone.

Caseworkers offered to return to Murwillumbah the following day and transport JM and children to Tweed Heads where she could organise her flights

JM JM to Victoria (offer was declined by ). provided her mobile number to caseworkers and agreed for them to call her the next day to see if she needed additional accommodation or other support.

Before leaving Murwillumbah to return to Tweed Heads, the caseworkers JM telephoned their manager to talk about their conversation with and observations of the children. The caseworkers advised the manager that there were no immediate safety concerns or dangers identified during the safety assessment and the children were safe in the mother’s care.

82. Later in the day police dispatched to hotel and evicted ’a couple’ for ’rowdy Tab 53 – Internal Death behaviour’. Review at pp. 11921193.

CAD record – inft “CAN HEAR MAL POSSIBLY ASS AF AA 2 CHILDREN CRYING WHILE ON CALL POI WAS SEEN OS UNIT - POI DESC Exhibit 9 – CAD record – ABORIGINAL APP 5FT10 SKINNY BLK HOODIE BLK LONG PANTS NIL Tweed River Hotel at p.

MENTION OF WEAPONS AMBOS DECLINED POI MAY BE ICE 1.

AFFECTED”.

Narrative : Police attended and spoke with all parties. The male and female were evicted from hotel for rowdy behaviour . There was no offence detected.

The male appeared to be a bit simple and was clumsy in actions. The family was clam and spoke freely with police. She laughed when police asked if anything happened to her. She said she had nil fears and there was no argument. She was unhappy with being asked to leave and that was it. They were planning on going back to Victoria the following day and were making their way to Coolangatta for the night where their flight was departing from. Nil fears for anybody’s safety. Nil offence. Nil argument. Nil DV.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) No mention of children in CAD narrative.

83. 17 October 2018 from made a formal notification to the DCJ Helpline regarding Tab 63 – Statement of the family’s homelessness. at p.1381, [29].

The DCJ Helpline initially screened the report made as ‘Risk Of Significant Harm’ for ‘Neglect: Inadequate Basic Care’ and recommended a response be Exhibit 4 – NSW DCJ provided in less than 10 days. bundle re reports and assessments pp. 92-93.

Later reviewed by Helpline SR Pilot managers who requested caseworker obtain further details. Tab 53 – Internal Death Review at pp. 1191The Helpline Caseworker tried to contact from at 5:05pm to 1193.

obtain more information however was advised to call back tomorrow.

Tab 55 – Statement of Meanwhile, QCS provided information about its involvement with the family at pp.

while they lived in Queensland. 1218, [33]-[34].

JM attempted to contact by phone however she did not answer Tab 115 – Report of the calls or respond to the voicemail message. Alison O’Neill at pp.

1923-1924.

84. 18 October 2018 Early afternoon, Helpline Caseworker contacted and spoke to a support Tab 63 – Statement of worker (not ) to ask for clarification on the report received. at p. 1381, [29].

Helpline Caseworker then contacted the Tweed River Motel reception and JM spoke to a male at 4:25pm. Confirmed was given 2 nights Exhibit 4 – DCJ JM accommodation…arrived with “a man” who said was “just dropping notifications and her off”. However the man was still at the motel the next morning. associated documents at pp. 92-93.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Receptionist said Police were contacted on Tuesday by another guest as the Tab 53 – Internal Death male caused a “disturbance”. The receptionist would not provide details of the Review at p. 1193.

disturbance and advised the Helpline Caseworker to contact Police to obtain Tab 115 – Report of additional information. Helpline Caseworker contacted Murwillumbah Police at Alison O’Neill at p. 1925.

5:23pm and was told about the occurrence as recorded in the CAD record at entry 81 above. Tab 55 – Statement of at pp.

The Helpline Caseworker consulted with her team manager and a decision 1219, [36].

was made to re-screen the report as non-ROSH.

The report was then referred to Tweed Heads CSC at 7:33pm, recommending the CSC “liaise with Victoria Child Protection because of concerns that JM may be avoiding child protection services by travelling between states.” JM Meanwhile, attempted to contact by phone however she did not answer the calls or respond to the voicemail message.

85. 19 October 2018 Safety Assessment outcome: completed a written safety assessment Tab 53 – Internal Death (SARA) in ChildStory. The document referred to QCS’s previous involvement Review at p. 1195.

with the family and referred to “Dispatch records show ‘Police attended and spoke with all parties but not noted DV”, however these details not factored Tab 55 – Statement of into the Safety Assessment. at pp.

1219, [38], 1289, 1292The safety assessment finding of ‘safe’ remained unchanged from the original 1295.

assessment that was completed on 16 October 2018.

Tab 115 – Report of Alison O’Neill at p. 1925.

JM

86. 20 October 2018 In Palm Beach Coolangatta, Ms Reid, a member of the public, gave Tab 100 – Statement of a double pram, items for the children, and money. She returns to where the Christine Reid pp. 1696van was the next day with more items for the family but the van was not there 1700.

and she could not find it.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) JM is not wearing any shoes but the children have clothes on top but Tab 100A – Statement of

JM RB only nappies as bottoms. Both and interact with Ms Reid Christine Reid pp. 1701appropriately. 1704.

87. 22 October - 26 away from Tweed Heads CSC attending mandatory ChildStory Tab 55 – Statement of October 2018 training in Sydney. at p.

1220, [43].

Tab 53 – Internal Death Review at p. 1195.

Tab 115 – Report of Alison O’Neill at p. 1925

88. 25 October 2018 Mr Neely, a member of the public describes seeing the family with a black van Tab 90 – Statement of RB with the children in Bay Street Tweed Heads. When cared for by the John Neely pp. 1645, RB children would be crying loudly and for extended periods. was 1647-1648.

RB constantly swearing and yelling profanities. On this date he saw JM brandishing a stick in a striking motion at who had the infant in her arms. She ran away from him leaving the toddler near the side door of the van.

Mr Neely calls ‘000’, and later sees a police car drive past but was not able to speak with police. On 29 October 2018 he takes a picture of the same van in case he needs it for the future.

RB

89. 27 October 2018 The QPS respond to report in Coolangatta regarding They issued him Tab 83 – Statement of RB with a notice for yelling and swearing at people. had an outstanding Tina McCarthy at pp.

warrant for a failure to appear. He was chased by Police on foot over the 1619-1620, [15]-[19].

border to NSW, and then they were unable to arrest him because he was in RB NSW. informed the police he was homeless and living in parks with his Tab 6 – Statement of partner and two young children. Daniel Lovell at pp. 7778, [66].

There did not appear to be a corresponding report to Child Safety.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) RB Tina McCarthy reports, on an unknown date, throwing a can of bourbon Tab 6b – Statement of at her and that he hit her on the back of her legs with a bat. She records that Daniel Lovell, the Coolangatta Police are called. Chronology of QPS Holdings at p. 147.

Tab 115 – Report of Alison O’Neill at p. 1926.

90. 31 October 2018 Risk Assessment completed by NSW DCJ: scored the risk Tab 55g – Statement of assessment as ‘High (Neglect).’ Risk Assessment at pp. 1296- “…. At the time of the assessment, JM stated to CW’s that she planned 1308.

to return to Victoria on 18/10/18 because she has family support there and will live with them while she gets back on her feet. CW has not been Tab 115 – Report of able to reach JM since this time to confirm she and the children went to Alison O’Neill at pp.

Victoria. JM did provided [sic] CW a forwarding address and 1926-1927.

CW will send an Interstate Notification to Victoria and QLD.”

91. Late October 2018 Michael Ward, a member of the public sees a father in a rage, strike the Tab 94 – Statement of mother in the head with an open hand whilst she is carrying the baby and then Michael Ward at pp.

throw the older child into the van from about a metre away. The father then 1672-1673, [9]-[12].

calmly drives away. This occurred in Bay Street Tweed Heads. Mr Ward understands that the police are called by staff at the Seascape Apartments.

RB JM

92. 1 November 2018 Senior Constable Chayne Foster (NSWPF) issued and with Tab 30 – Statement of Field Court Attendances Notices for driving a vehicle with the children Chayne Foster at pp.

unrestrained in the back. NSWPF also later (5 November) made a notification 888-900.

to DCJ reporting a Risk of Neglect. See further details below.

Tab 115 – Report of Alison O’Neill at pp.

1927-1928.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

93. Early November calls both the Police and (she believes) FACS Tweed Heads Tab 77 Statement of 2018 (probably 2 (which was in fact Tweed Heads Family Centre) and describes concerns at pp.

November 2018) regarding a family in a van. She also calls NSW Police Headquarters because 1599-1600, [28]-[33].

she felt frustrated at not being taken seriously, she is transferred back to Tweed Heads Police Duty Officer and is told that the police would get to it as soon as they could. Later she is called back by the Police who indicate that they have located the black van but could not see anyone with it and it is explained that the Police had done all they could.

Call leads to Police Response at Number 95. Transcript for 19 December 2023 at p.

81:11.

94. 2 November 2018 receives an email from the Family Centre, where she is informed Tab 77 – Statement of that FACS requires the names of people to make a Mandatory Report. at p. 1602.

95. 2 November 2018 and Tab 32 – Statement of attended a park in Tweed Heads after receiving a call from a at pp. 924member of the public about a family with a toddler and a baby living out of a 933.

JM black van for the past few days. The officers spoke to and noted that “both children appear to be well fed, appeared clean and not showing any Tab 33 – Statement of signs of not being looked after by their parents”. The officers enquired if at pp.

JM RB had tried to source accommodation and she indicated that 934-935.

“did not like handouts or assistance from the government”.

Tab 115 – Report of Alison O’Neill at pp.

1928-1929.

96. 4 November 2018 Subsequent to the NSWPF interaction with the family on 1 November 2018, Tab 30e – Statement of S/C Foster creates COPS Event E 72382853 incorporating a ‘Child/Young Chayne Foster, Event Person at Risk’ Report noting that the children were at risk of significant harm Ref No: E 72382853 at p.

due to ‘Neglect – Physical Shelter/ Environment’ as they had been living out of 915.

their vehicle for a month.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 53 – Internal Death “Father is alcohol dependent. Children located in back of van on a bed. Not in Review at pp. 1197a seat and not secured by a seatbelt. The father has extensive history with 1198.

Police in both NSW and QLD where alcohol is a major factor to him coming under notice….The child was dirty in appearance and clothes dishevelled. Tab 115- Report of Child is living with father and mother in a van where there is no apparent Alison O’Neill at p. 1929.

sufficient food or shelter. Not covered with appropriate clothing.” Transcript for 19 verified by supervisor on 5 November 2018 and automatically December 2023 at p.

referred to DCJ. 62:3.

Report appears to have remained in backlogged queue of 1560 outstanding contact records at the Child Protection Helpline, until it was referred to the Helpline’s SR Pilot team on 17 November 2018.

97. 6 November 2018 Subsequent to the NSWPF interaction with the family on 2 November 2018 (in Tab 33A – Statement of a Tweed Heads park), S/C Jennings created a ‘Community Service Report Matthew Jennings, Event and noted concerns for the family as “not in current housing and living out of Ref No: E 70143374 at van with parents. Only issue and staying in Park during the day…the pp. 929-931.

children’s physical and emotional state appears both children appear find.

Dressed and appeared well fed.” Tab 6 – Statement of Daniel Lovell at p. 80, Assessment officer at Police Child Wellbeing Unit records entry in ChildStory [69].

with Short Description “Passer-by has reported concerns Baby Q (9 months) and LB (1) were unsupervised and family living in a van. Police attended Exhibit 11, Second where family advised repairs being done on van and they will soon be moving Addendum statement of off to Victoria. Open with Tweed Heads CSC” Mark Dixon at p. 5 [22] Entry in ChildStory does not come to the attention of Tweed Heads CSC. Tab 115 – Report of Alison O’Neill at p. 1929.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

98. 7 November 2018 Aboriginal Elder Dianne Jacob met with the family in Byron Bay. Ms Jacob said Tab 73 – Statement of RB (approx.). that prior to the family leaving Byron Bay, asked her to take both his Dianne Jacob at p. 1575 children because he was an alcoholic and using marijuana. [8].

Tab 6 – Statement of Daniel Lovell at pp. 8081, [70]- [71].

Tab 115 – Report of Alison O’Neill at p. 1930.

RB involved in a motor vehicle collision in Byron Bay. Senior Constable Tab 39 – Statement of RB Rebecca Krilich and Senior Constable Cooke (NSWPF) attended. Rebecca Krilich at pp.

returned a positive reading for alcohol. He was unkempt looking, slurring his 944-947.

speech and his eyes were bloodshot and glazed. He was taken to Byron Bay JM Police Station and cautioned. and the children were present Tab 115 – Report of however it is unclear if they were in the car at the time of the collision. Alison O’Neill at p. 1930.

99. 8 November 2018 sent an interstate notification to Vic Human Services outlining Tab 55h – Statement of LB Baby Q concerns for and identified in the risk assessment. The case was then closed on ChildStory with the reason ‘Client relocated’ with the rationale Interstate Risk of Harm ‘At this time it is believed the family have relocated to Lara, Victoria. An Notification at pp. 1309Interstate Risk of Harm notification was sent to VIC DHS with forwarding 1313.

address provided. Risk Assessment was High.’ Tab 115 – Report of Alison O’Neill at p. 1930.

RB

100. 10 N ovember 2018 was stopped and searched by NSWPF in Casino NSW after police Tab 6 – Statement of received information that he had been wielding a crowbar in a threatening Daniel Lovell at p. 82, manner. Police located bicycle handlebars in his possession which he claimed [73].

to have for protection. He was issued with a move-on direction and indicated JM he was catching a train out of Casino that night. No reference to or Tab 115 – Report of RB the children being with Alison O’Neill at p. 1931.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) RB RB

101. 15 N ovember 2018 The QPS arrested by virtue of a warrant in Brisbane, QLD. was Tab 6 – Statement of JM transferred to the Brisbane City Watch House. was present at the Daniel Lovell at pp. 82, time of his arrest. The records do not refer to the children. [74].

Tab 6b – Chronology of QPS Holdings at p. 147.

Tab 115 – Report of Alison O’Neill at p. 1931.

RB

102. 16 N ovember 2018 At 11:48am and 7:45pm (AEDT), the QPS had interactions with in Tab 6 – Statement of relation to concerns for welfare and then later being with a group who were Daniel Lovell at pp. 83, drunk/drinking in the park. The QPS holdings record: ‘Street check. [78].

CAD event for welfare check. Nil issues. POIs [persons of interest] did not want to speak with police’. The records do not refer to the children. Tab 6a – Statement of Daniel Lovell, chronology At approximately 6:13pm, Police were called to a large group of intoxicated of QPS Holdings at p.

Indigenous males causing trouble. They failed to find a group causing trouble. 146.

RB JM LB Baby Q At approximately 6:45pm they observed , and Tab 37 – Statement of from a distance. S/C Scott observed the children being pushed in a shopping Tracy Scott at p. 941, [7].

trolley dressed only in nappies.

115 – Report of Alison O’Neill at p. 1932.

103. 17 N ovember 2018 At 12:45am (AEDT), Senior Constable Michael Zairis and Constable Cassie Tab 12 – Statement of Dorricott (QPS) located the family sleeping in a park at the intersection of Michael Zairis at pp. 266Chelsea Avenue and Old Burleigh Road, Broadbeach. A complaint had been 274.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) received from a member of the public about the children sleeping outside dressed only in nappies. Tabs 12(a), 15(a) – BWV (available upon request).

RB JM LB The officers found and sleeping on the ground with and Baby Q in between them. The children were only wearing disposable nappies Tab 15 – Statement of RB and the family had limited food and water. was described as intoxicated Cassandra Dorricott at JM and unwilling to discuss the families’ situation. said they did not like pp. 317-321.

living in a house because it was “cramped” and declined officers’ offers of assistance. The officers formed the view that “although the children appeared Tab 115 – Report of to be healthy and not malnourished from what we could see, we were Alison O’Neill at p. 1932.

concerned the parents were not able to care for the children given the very limited food and basic requirements they had in their possession.” Assistance was sought from Plain Clothes Senior Constable Adrian Bisa and Plain Clothes Senior Constable Chloe Barton Gold Coast District Child Protection & Investigation Unit.

104. At 1:27am (AEDT), body worn camera footage depicts PC S/C Bisa and PC Tab 10 – Statement of RB JM S/C Barton arriving at the scene. In response to and being Adrian Bisa at pp. 237informed that it was not acceptable to have a 9-month-old child living on the 261.

JM streets, suggested she might be able to arrange travel to Victoria to RB live with her parents, however objected to this and said it was none of Tab 11 – Statement of their business. The officers determined that the best course of action was to Chloe Barton at pp. 262take the family to a ‘place of safety’. The officers assisted the family to travel to 265.

Paulette Butterworth’s address in Kingscliff.

Tabs 10(b), 12(b)-(d), PC S/C Bisa knocked on Ms Butterworth’s door however did not receive a 15(b)(c) – BWV response. He then spoke to a neighbour and confirmed that the apartment was (available upon request).

RB Ms Butterworth’s address. After attempts to raise Ms Butterworth, RB entered the unit through an open bathroom window. located paperwork in the unit, which was addressed to Ms Butterworth, who was not home at the Tab 115 – Report of time. At approximately 4:00am (AEDT) officers left the family at Ms Alison O’Neill at pp.

Butterworth’s residence. 1932-1934.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Upon returning to Burleigh Heads Police Station, PC S/C Bisa created a ‘Report of Suspected Harm – 520 Report’, noting that the children were sleeping in a park in Broadbeach with “minimal possessions, minimal clothing, minimal food, no money or access to money until Wednesday the 21/11/2018.’ Report of Suspected Harm needed to be reviewed internally within the QPS Baby Q before sent to QCS. Ultimately received by QCS after had died.

105. At 9:32am (AEDT), CCTV footage records the family boarding a bus at Tab 6 – Statement of Kingscliff bound for Tweed Heads. The family went into Tweed Heads Daniel Lovell at p. 85, Shopping Centre before boarding another bus outside the shopping centre at [84].

10:42am.

Tab 115 – Report of Alison O’Neill at p. 1937.

106. At 10:52am (AEDT), CCTV footage records the family getting off a bus at Tab 6 – Statement of Tweed Heads. The family then spent the remainder of the day in the vicinity of Daniel Lovell at p. 85, Chris Cunningham Park and Jack Evans Boat Harbour, located at the [85].

intersection of Wharf and Bay Streets, Tweed Heads.

Tab 115 – Report of Alison O’Neill at p. 1937.

107. About 2:30pm (AEDT), the family approached a homeless woman, Kirsty Tab 6 – Statement of Baby Q Davis, in Chris Cunningham Park, and had a discussion about giving to Daniel Lovell at p. 85, RB Baby Q Ms Davis. asked Ms Davis to take permanently, and he [86].

persuaded the mother to hand her to her. Ms Davis followed the family and Baby Q returned to them and said that she could not look after the baby when Tab 115 – Report of she lived on the streets. About an hour later, the family saw the woman again, Alison O’Neill at p. 1937.

Baby Q and again there was an attempt to give to her, but she refused.

Number Date/Time (NSW) Event Reference (at p. # of

BOE)

108. During the late afternoon/early evening a large storm accompanied by heavy Tab 6 – Statement of rain impacted the Tweed Heads area and the family took refuge under a multi- Daniel Lovell at p. 86, level car park located at the Tweed Mall adjacent to Chris Cunningham Park. [88].

109. Between 6:34pm and 6:37pm (AEDT), CCTV footage records the family at Tab 6 – Statement of JM LB Baby Q Tweed Mall. was carrying and was in a shopping Daniel Lovell at pp. 86trolley. 87, [89]-[90].

Around this time, a witness, Emily Gregory reported seeing the family in the car RB park near the Bay Street entrance. Ms Gregory observed holding Baby Q to his chest with a red and black blanket wrapped over her. She RB Baby Q JM observed , who was still holding walk away from and LB down a ramp leading to Bay Street. CCTV footage confirms that the

JM LB and remained in the car park.

110. At 6:47 (AEDT), a witness, Paul Thompson, observed a male matching Tab 6 – Statement of RB description walk along the Southern footpath of Bay Street. The male Daniel Lovell at pp. 88, had a blanket wrapped around his body. The male walked towards the river [92].

and climbed over the rocks (shoreline) moving close to the water. The male thew an “object” into the river. He moved back to the grass next to the river and Tab 115 – Report of fell onto his knees before lying flat on his stomach. He moved his hands to the Alison O’Neill at p. 1937side of his head. The male laid in this position for at least 10 minutes. At least 1938.

three other witnesses who reside near the Tweed River observed a male lying on his stomach next to the riverbank in the pouring rain for a period of time.

Further witnesses, Joanne Newman and John Waterhouse reported seeing a male lying on the ground next to the river, and item(s) floating in the river. Ms Newman described seeing two separate items, “One was white and one was black. The white item looked like a t-shirt or a small towel, it was floating just under the surface.. about the same size as a tea towel or nappy… The black item was rounded on top and seemed to float on top of the later, it was buoyant…”. Mr Waterson described the object as a “black coloured reasonable sized squarish object in the river. It was a shape more than a blob. I watched

Number Date/Time (NSW) Event Reference (at p. # of

BOE) the item for about 30 seconds as it bobbed up and down through the rough waters of the river towards the sea on the outgoing tide.” RB

111. At 7:01pm (AEDT), CCTV footage records that returned to the car park Tab 6 – Statement of JM LB RB at Tweed Mall and met with and . returned without Daniel Lovell at p. 91, Baby Q [97].

112. Unspecified time on 17 November 2018: an intake officer at the DCJ Tab 53 – Internal Death Helpline noticed the police e-report made on 5 November 2018 had not been Review at pp. 1197processed and referred to the Helpline SR Pilot team for assessment. The 1198.

LB Baby Q reported concerns, which were that and had been living out of a van for a month, were initially screened as meeting the ROSH threshold.

Further information obtained from VIC Human Services and Tweed Police.

After reviewing the previous safety assessments by Tweed Heads CSC, the report was re-characterised as non-ROSH and the report was closed at the Helpline.

RB JM LB

113. 18 N ovember 2018 At 4:54am (AEDT), and boarded a bus at Griffith Tab 6 – Statement of Street, Coolangatta, bound for Broadbeach. They subsequently made their Daniel Lovell at p. 92, way to Surfers Paradise over the course of several hours. [99].

114. At 12:50pm (AEDT), Police officers patrolling Surfers Paradise were alerted to an Indigenous male yelling and screaming in the streets and conducting Tab 115 – Report of himself in an aggressive manner. The Police attended and observed RB Alison O’Neill at p. 1938.

acting irrationally. He referred to his daughter being “with the elders”.

RB was arrested for public nuisance and conveyed to Southport Watch House, where he was released shortly after 5:00pm that afternoon.

115. 19 N ovember 2018 At about 1:25am (AEDT), a witness, Alexander Owen, was walking along the Tab 6 – Statement of Baby Q beach at Surfers Paradise and discovered body approximately three Daniel Lovell at p. 94, to four metres above the waterline. Mr Owen contacted emergency services [102].

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Baby Q who attended and attempted to resuscitate At 1:51am (AEDT), QLD Tab 115 – Report of Baby Q Ambulance service pronounced life extinct. Alison O’Neill at pp.

1938-1939.

116. Shortly after 1:36am (AEDT), Senior Constable Taulapueoko Sipu and Tab 28 – Statement of Constable Corey Lawrence responded to reports of a domestic violence Taulapueoko Sipu at pp.

RB JM incident between and at Broadbeach, QLD. A member of 704-708.

RB JM the public had witnessed punch in the head. The officers

RB JM LB located and sleeping on the ground. They noted that Tabs 28(a)-(b) – BWV

RB JM was uncooperative, and was withdrawn and had bruising to (available upon request).

her left eye.

Tab 25 – Statement of JM denied any domestic violence however said that they were upset Corey Lawrence at pp.

because someone close to them had passed away. Cst Lawrence recognised 649-652.

RB JM and , and after establishing that there was only one child with them and being aware that a deceased child had been located on the Tab 115 – Report of beach at Surfers Paradise, he called his Shift Supervisor and informed her of Alison O’Neill at p. 1939his suspicions about the identity of the deceased child. 1940.

RB was detained and taken to Broadbeach Police Station, before being transported to Southport Watch House and arriving at about 2:45am (AEDT).

JM LB and were also taken to the police station.

RB

117. At about 5:16am (AEDT), Senior Constable Ramsey placed under Tab 28 – Statement of Baby Q arrest for the ‘unlawful killing’ of at the request of the QPS Criminal Taulapueoko Sipu at p.

Investigation Branch. 707, [36].

JM

118. Between 3:48am-4:40am (AEDT), participated in an electronically Tab 26 – Statement of recorded interview with Detective Sergeant Troy Quinn at Broadbeach Police Troy Quinn at pp. 653Station. 658.

Tab 26(a) – ERISP (available upon request).

Number Date/Time (NSW) Event Reference (at p. # of

BOE) Tab 26(b) – ERISP Transcript at pp. 660681.

RB

119. Between 2:07pm-3:02pm (AEDT), was recorded in his cell confessing Tab 6 – Statement of Baby Q to killing by throwing her in the Tweed River because she was evil and Daniel Lovell at p. 97, he wanted to rid the world of her. [110].

Tabs 20(a)-(f), Transcripts at pp. 340434.

RB

120. Between 4:03pm and 4:34pm (AEDT), participated in an electronically Tab 6 – Statement of recorded interview with Detective Senior Constable Renee O’Dell at Southport Daniel Lovell at p. 97, Baby Q Watch House in which he made admissions to killing [111].

Tab 21(a) – ERISP (available upon request).

Tab 21(b) – Transcript at pp. 440-464.

121. 20 N ovember 2018 Dr Andrzej Kedziora, Forensic Pathologist, Queensland Forensic and Scientific Tab 2 – Autopsy report at Baby Q Services, conducted a post-mortem examination of The cause of pp. 2-20.

death is listed as undetermined.

JM

122. 21 A ugust 2019 appeared before Magistrate Dunlevy at Tweed Heads Local Court Tab 9 – Investigator’s charged with failure of a person with parental responsibility to care for a child Note at p. 236.

(cause danger or death). She was discharged under s 32(3)(a) of the Mental Health (Forensic Provisions) Act 1990 (NSW) and was ordered to comply with all directions and conditions imposed under her Victorian Community Treatment order, and released into the care of her father.

Number Date/Time (NSW) Event Reference (at p. # of

BOE) RB

123. 4 N ovember 2020 appeared before Justice Wilson in the Supreme Court of NSW and Tab 8 – R v RB at p. 22, Baby Q found ‘not guilty by reason of mental illness of murder and ordered [7].

that he be detained under s. 38 of the Mental Health (Forensic Provisions) Act 1990 (NSW). Tab 115 – Report of Alison O’Neill at p. 1943, [12].

Glossary of terms Acronym Meaning ACT Acute Care Team ANC Additional Notified Concern ATSI Aboriginal and Torres Strait Islander CAD Computer Aided Dispatch CCR Child Concern Report CIMHA Consumer Integrated Mental Health and Addiction COPS Computerised Operational Policing System CSC Community Services Centre CST Constable DCJ Department of Communities and Justice (NSW)

(at times also referred to as Department of Community Services (DOCS), or Family and Community Services (FACS)) DHS (VIC) Department of Human Services, Victoria D/S Detective Sergeant D/W Discussed With HHOT Homeless Health Outreach Team I & A Investigation and Assessment ITO Involuntary Treatment Order NSWPF NSW Police Force PARC Prevention and Recovery Centre PC S/C Plain Clothes Senior Constable POI Person of Interest QCS Department of Children, Youth Justice, and Multicultural Affairs (at times also referred to as Queensland Child Safety) QPS Queensland Police Service ROSH Risk of Serious Harm SARA Safety and Risk Assessment SCAN Suspected Child Abuse and Neglect (Team) TUW Take up with