Finding into death of Hayley

Rule 60(1)

FORM 37

REDACTED FINDING INTO DEATH WITH INQUEST

Court references 3753/09

Section 67 of the Coroners Act 2008

; Inquest into the Death of HAYLEY

Delivered On:

’ Delivered At: Hearing Dates:

Findings oft

‘Representation:

Place of death:

Counsel Assisting the Coronet!

19th October, 2014.

Ballarat Magistrates’ Court

100 Gronville Street South, Ballarat 3350

21th June to 6th July, 2011 Inchisive

8th July, 2011

JOHN OLLE, CORONER

Ms J, Benson appeared of behalf o

Mr M. McLay appeared on behalf of

Wimmera Uniting Care

Mr M, Simon appeared on behalf of

St Amand Childcare -

Mr I. Hamnebery appeared on beha K, Wheeler and J, Bongiorno

Mr T, Butns appeared on behalf of and J, Bruce

Mtr R, Gipp appeated on behalf of # Chief Commissioner of Police

DES

if of,

G, Paterson

TO

MrT, Lavery appeared on behalf o:

fSR

Royal Children’s Hospital, 50 Flemington Road, Parkville 3052

of Victoria at Ballarat

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Mr C. Winneke of Counsel in the Coroners Court

' FORM 37 Rule 60(1)

REDACTED FINDING INTO DEATH WITEINQUEST . Section 67 ofthe Coroners Act 2008

Court reference; 3753/09 nthe Coroners Court of Victoria at Ballarat I,JOHN OLLE, Coronet having investigated the death of; Details of deceased:

Sumame; :

Firstname: HAYLEY

Address: Atnard, Victorla 3478 AND having held an inquest in xolation to this death on 27th June, 2011 to 6th July, 2011 and 8th Tuly, 2014 : ; at Ballarat Magistrates’ Court find that the identity of the deceased was HAYLEY and death occurred on 2nd August, 2009

‘at Royal Childtens Hospital, 30 Flemington Road, Parkville 3052

from ; la, HEAD INJURY

in the following circumstances:

PURPOSES OF A CORONIAL INVESTIGATION

L The primary purpose of the coronial investigation of a reportable death?? is to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death occured, The practice is to refer to the medical cause of death incorporating whore approptiate the mode or mechanism of death, and to limit investigation to circumstances sufficiently proximate and causally relevant to the death,

2, Coroners are also empowered to report to the Attorney-General on a death they have investigated; the power to comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice; and the power to make

TD Scotion 4 of the Acl requizes cortaln denths to be reported to the coroner for Investigation, Apart from a Jorisdictlon nexus with fhe Stute of Victoria, the definition of a reportable death includes all deaths that appear "to have been unexpected, ynnatural or violent or fo have resulted, direotly or indireefly, from acoldent or injury."

20 Section 67 of the Avot, ‘

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_recommendations to any Minister, public statutory or entity on any matter connected with the death, including secommendations relating to public health and safety or the admainiste ation of Justice.2!

3, The focus of a corontal investigation is to determine what happened, not to ascribe guilt, alivibute blame or apportion Hability and, by ascertaining the ciroumstances of a death, a coroner can identify opportunities to help reduce the likelihood of similar occurrences in future,

BACKGROUND

© Hayley was born on 30 May 2007, She was the second child of Robert and CG, She had an older sister, JG, and two brothers SM and AG

e In November 2008, the family relocated to a rental property at St Arnaud (‘the home"), Shortly aftecward, the parents separated. CG was pregnant with their third child, The couple had separated on prior occasions.-The relationship featured complexities of family violence, accommodation instability, financial strain, drag and alcohol misuse, .and other social difficulties,

® Following sepatation, Hayley and SM remat ined at the home with their father,

.@ InPebruary 2009, Robert commenced # new relationship with a neighbour, SR. SR and her 6-

yeat-old daughter, TW moved into the home. : ,

© On7 April 2009, Hayley and SM commenced childcave at the St Arnaud Children’s Precinct ("childcare"),

4, The family had a long-standing involvement with the Department of Human Service Child Protection Service (DHS) dating back to 2004, The full extent of this contact, spanning many yeas, was beyond the scope of my investigation, DHS also had a history of involvement with SR dating back to 2004,

5, From carly May 2009, it. was apparent that Robert's personal circumstances were becoming inoveasingly problematic, In patticular, Robert:

e had fallen behind his rént and childcare fees;

© had minimal contact with his parents; ‘

9 was finding the demands of cating for two young childien iticreasingly diffienlt; e was drinking heavily;

e was regnlatly involved in loud arguments at home;

o he looked vague, avoiding eye contact and communication;

• displayed confusion; and

e was late collecting the children from childcare,

aT Sections 72(1), 72(2) and 67(3) of the Act sogarding reports, recommendations and comments respectlyely.

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6. My investigation has primarily focussed on the months leading up to Hayley’s death. A chronology prepared by the patties has accurately set out all relevant events and will yemain on the coronial file,

7, Concoms were raised with authorities in relation to Hayley (and SM) in the month leading up to her death, including preseritations of injuties at childcare on: 17 June 2009 (Hayley presented with scratches and binises on her cheeks), 22 June 2009 (Hayley has ‘purple looking lip... face has come up with bruises around scratch marks on the tlght hand side,’) and 29 Jime 2009 (Hayley presented with two black eyes and a raised lump on her forehead).

CIRCUMSTANCES OF DEATH

8, On 7 and possibly 8 July 2009 Hayley, aged two, sustained serlous injuries at her homo, In the early hours of 8 July 2009, her father, Robert, conveyed Hayley to the St Arnaud Hospital, On admission, Hayley was assessed as being in a oriticul condition, Within hours of admission, she was airlifted to the Royal Children’s Hospital, She subsequently died on 2. August 2009,

9 Theve is uncertainty as to the manner In which Hayley suffered the injuries which led to her death, It was however clear that Hayley suffered those injuries at her home in the compaty of her primaty carer and father, Robert, his pattnex, SR and her brother, SHR, The injuries Hayley suffered appear to have occured in an aggressive and violent atmosphere fuelled by the excessive consumption of alcohol by the adults present,

10. Dy Andrea Smith of the Victoria Forensic Paedlatcic Medical Service noted that Hayley had suffered a consteltation of injuries, including head injurles which resulted in severe brain infury, ‘The post mortem examination conducted by Dr David Ranson, Deputy Director of the Victorian Institute of Forensic Medicine, on 3 August 2009 determined that the medical cause of Hayley’s death was head injury.

ii, Of relevance to this investigation, Talso conducted a contemporancous investigation into the death of Rohert, I determined in that matter that Robert died as a result of hanging on 13 Tuly 2009 in circumstances where he intended to take his own life,

UNCONTENTIOUS MATTERS

12, At the completion of the police investigation and prlor to the commencement of the inquest, Jt was appazonl that a number of the facts about Hayloy’s death are known and were uncontentious, These include the deceased's identity, the medical cause of her death and aspects of the circumstances, including the place and date of her death,

13, Given this, I formally find that the deceased was Hayley, born on the 30 May 2007, late of St Arnaud; that she dled on the 2 August 2009 at the Royal Children’s Hospital located at 50

Flemington Road, Parkville; and that the medical cause of her doath is “head injuries",

THE FOCUS OF THE INVESTIGATION

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Introduction ,

14. The Inquest Brief prepared for this investigation is comprehensive, Investigative short: comings following Hayley’s death have beet identified,

15. All interested. parties, in particular, Victorla Police and DHS fully co-operated with my investigation, Witnesses provided frank and fortheight evidence at the inquest, Individual shottcomings were acknowledged, The witnesses displayed a collective determination to ensure identified deficiencies are never repeated,

16, DHS and Victoria Police have acknowledged a host of serious deficlenoies in their investigative roles in the weeks leading to Hayley's death, To the ctedit of each organisation, wide ranging systemic improvements have been instigated across Victoria.

17, - The professionals involved in Hayley's case could not have reasonably foreseen her

imminent rise of death, Having consldered all the evidence I am ynable to conclude that any individual failing contelbuted to Hayley's death, Further, I am not satisfled that the absence of the identified systemic failings would have necessarily averted the tragic outcome, A conclusion such as this would be’ based on speculation only, I am however able to say that the system designed to support the protection of children in Victoria did not serve Hayley well and the tragle and distressing cirenmstances of her death must be a catalyst for change.

How did Hayley sustain the injuries which lead to her death?

18, Hayley suffered injuries during 7 July 2009 and possibly on 8 July 2009 prior to being taken to hospital, After considering all the avatlable evidence uncertainty yemains as to the manner in which Hayley suffered the injuries,

19, It 4s probable that Robert caused some of the injuries to Hayley. It may also be the case that SR caused some injury to Hayley. The extent of those injuries is unclear, It is also not clear which injury or injuries dllimately caused Hayley’s death, and on the state of the evidence, it is difficult to conclude which of the two was responsible, .

20, Thete 1s no suggestion from either Robert or SR that SR’s brother ShR caused any injuries to Hayley. His role is restricted to that of an individual who witnessed and did nothing to stop the abuse suffered by Hayley over a prolonged period,

21, Inorder to conclude that one or other of those persons (namely Robert or SR) inflicted the injuries that ultimately were the cause of death, I would need to be satisfied by clear and cogent uvidence.% ‘The faot that Robert is deceased does not lessen that standard,

22. Briginsha v Brighishay

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92, ° Upon the applications of SR and ShR, I excused both individuals-from giving evidence,23 T accept that the absence of thelr evidence cannot be used to fill evidentiary gaps, or strengthen available evidence which suggests SR’s involvement, As none of the three adults at the house have given evidence on oath, no version has been tested by cross examination. An examination of each version of events as outlined in their written statements falls to explain how Hayley sustained her injuries with any certainty, On the basis of this exercise it is difficult to elevate one yorsion over another, :

93, It is clear that each adult was drinking heavily over the hours of Hayley’s ordeal, Sometime around 8,00pm that evening, SM and TW were put to bed but Robert kept Hayley up as punishment for being naughty, It appears that Hayley was required to stand in a comer for an extended poriod, possibly hours, Tt 4s apparent that Robert was unable to cope with a two-year- " old and that he demonstrated extremely poor parenting skills, These factors in combination with — excessive alcohol provided the setting for the tragic events,-The evidence does not however allow me to conclude that any adult present intended to cause fatal injuries to Hayley.

Was Hayley’s death preventable?

24, A child protection system which relies on notifications of alleged child abuse, is not the optimal systent to protect children - irrespective of the motivation, skill and dedication of staff or systemic officlency of a system which responds to alleged abuse. Prior to Hayley’s death her frmily was not considered in the highest of risk categories, dospite the multitude of issues faced © by the family, Ibis likely that a child protection system. designed to prevent abuse before it oconts was Hayley's best chance of survival - this is the single biggest learning from this investigation.

At inquest, dedicated and experienced staff urged a mind-shift from reaction to. early jnteryentlon,

25, The prevention of child abuse and neglect is not achioved solely through statutory involyement with child protection agencies and police criminal investigations, For (he most patt, these responses occur in the wake of harm to a child having already occurred, It 1s essential that investment therefore be made in programs designed to engage and assist families prior fo rerlous problems emerging and before particulat patterns of behaviour become entrenched.

INVESTIGATION OF CHILD ABUSE IN VICTORIA

26, Both Victoria Police and DHS Child Protection have a responsibility to investigate cases of suspected abuse of a child, .

VICTORIA POLICE

27, Yuring tho inquest, a series of concessions were made by Victorla Police in regard to the Hmitations and deficiencies of the investigation into the injuries sustained by Hayley,

2 As permitted by seetlon 57 of the Coroners Act 2008, See Comments : 25 submisston on behalf of the Chief Canmissioner of Police dated 8 July 2014

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28, In relation to the attendance at the St Arnaud Children’s Precinct on 30 June 2009, Victorla Police acknowledged that a more thorough investigation was required to identity the cause of Hayley’s injuries, Further, it was conceded that the significance of certain pieces of evidence were not fully appyectated; that photographs of her injurles and a forensic medical investigation should have been arranged; childcare staff should have been interviewed; and that police attendance at the family home to speak to Hayley's cavers was necessary, It was also acknowledged that relevant Victoria Police family violence policy and: procedural directions (including completion of the Family Violence Risk Assessment and Risk Managetnent Report - YP Form 1.17) were not adhered to, ‘

29, I note that the SOCAU member in attendanoe at the St Arnaud Children’s Precinct on 30 June 2009 was a relatively junior officer with limited exporlcnce carrying out investigations with young children, Under normal citoumstances, attendance would have occurred in the company of a supervising officer, Victorla Police identified that the supervision provided to the SOCAU member on the day was below standard, It was also noted that further direction should have been given, mainly in sespect to completing the various investigative tequirements outlined above, Tt was also acknowledged that farther inquiries with the DHS Child Protection service as to the availability of any other evidence was needed, prior to withdrawing police involvement,

30, Victoria Police conceded that the response following notification of Hayley's presentation *

to St Arnaud’ Hospital on 8 July-2009 similarly involved a number of shortcomings, It was accepted that police did not attend tho hospital nor the family residence at the earliest opportunity, thus delaylng the collection of information and evidence; that the three adults present on the evening Hayley was injured were not interviewed at the finst available opportunity; that there was no considevation given as to whether other childron were at risk when notification of Hayley’s condition was first received; and that the DHS Child Protection service was not notified or contacted in order to obtain a relevant family history...

31, Within Victorla Police, immediate liaison between the Victorla Polico CYU and SOCAT did not occurs contact was not made with police in Melbourne followlng Hayley’ s transfer to the Royal Childven's Hospital; and once again, internal family violence policies and procedures were not followed, It was acknowledge that all of these actions should have taken place.

32, The investigation that commenced on the inorning of 8 July 2009 at Hayley’s home in St Arnaud, was also found to be lacking in a number of ways, Here, Victorla Polico acknowledged thete was a failure for information to be communicated between CIU from SOCAU that possibly implicated SR as having conlributed to Hayley’s injuries; that a VATE interview with SR’s daughter should have been arranged al the earliest opportunity, that there was a failure to ascettain from SOCAU or the DES Child Protection Servico that Hayley had presented to childeare with injuries the previous weelc, and that a far greater lovel of scrutiny should have

• been applied to the accounts of Hayleéy’s injuriés provided by SR on the day,

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33, Nevertheless, Victoria Police maintain that sufficient evidence existed that implicated Robert in regard to Hayley’s assault and watranted the charges that were made, Prior to those charges being laid however, a more thorough investigation that gave consideration to a far greater range of available evidence might have taken place. At the very least, police should have spoken with workers at the St Arnaud Children’s Precinct regarding their observations about Hayley and SM, as well as obtaining a family history from the DHS Child Protection service as to the

• Department's previous involvement with both Robert and SR, Flaws with the record. of interview completed with Robert have also been identified and accepted by Victoria Police,

Remedial Activities in response by Victoria Police

34, Since Hayley’s death, Victoria Police have inttoduced a range of reforms to address the identified inadequacies both at the regional level and actoss the entire organisation, Some of these occurred in direct response to this event, while others were the result of long-term planned reforms, '

35, An example of the latter category has involved the transition of the Victatia Police SOCAU to what in now referred to as the Sexual Offence Child-Abuse Investigation Team (SOCIT), Members of SOCIT ate. required to have completed a qualification known as the Ficld Investigation Course, This is a competency based training program, which requites police. to initiate, conduct and finalise routine investigations, Membets are also requited to complete the Advanced Diploma of Public Safety (Police Investigations), formerly referred to as Detective Training School, . :

36. In addition, the Sexual Offence and Child Abuse Course must be completed, which fuvolves a focus on interview techniques with children, vulnerable witnesses and suspects, The Inquest heard that the introduction of the SOCIT has also meant an increase in the munbers of specialist investigators state-wide,

37. In zespect to the problems with the police investigation ocoutring on 30 June 2009, T note that the following steps have been taken in the Horsham region:

© imodifications (o staffing arrangements to ensure two members woul together wherever posslble and to enable supervision from an Officer in Charge of SOcIT;

e changes to the leave policy to improve staffing levels; increased Haison with the DHS and the 4ntroduction of three monthly meetings between the Department and the Officer in Charge of the SOCIT; ‘ ;

° completion of 4 compliance audit of what was then the Horsham SOCAU to cnsure compliance with policy and legislation; updating the Horsham Standard Operating Procedres in order to improve the responses to child abuse, with the requirement that photographs of Injuries be taken evon where it has been established that no crime is committed:

® stricter requirements regarding altangements for forensic medical investigations whether or not these injuries are thought to be attributable to child abuse; additional training in the area of interview techniques and family violence; and

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e circulation of fhe Memorandum of Understanding between the DHS and Victoria Police to all members in the Northern Grampians Police Service area, in conjunction wilh an email to all membors of the atea regarding the critical importance of Victoria Police adhering to family violence policies and procedures, including the appropriate use of the Victoria Police Form

LAT, , :

38, In zespect to the investigation conducted by Stawell CIU on 8 Iuly 2009, F noto initiatives to address the identified deficlts have included: .

© areview of the after-hours call out policy at the Noxthern Gramptans CIU; e areview of staffrostering at the Stawell/Avarat CIU;

e additional training packages regatding police responsibilities at crime scenes, with an

emphasis on the responsibilittes of supervisors; .

e further training regarding the collection of evidence and interview techniques;

othe development and distribution of the Frontline Supervisors’ Guide inclnding reference to orime scene management and tesponses to family violence matters; and ’

» increased levels of supervision at the commencement of investigations,

39. I note that Victoria Police as an organisation, remains committed to addressing family violence and child abuse, and that it recognises the need for police involvement in efforts aimed at identification of vulnerable children and carly intervention.

40, I was advised that police ate participants in the Grampians Family Violence Prevention Network and the Protecting Vulnerable Families initiative in the Norther. Grampians Shire; the appointment of’ Family ‘Violence Liaison Officers across the stale and including the Northern Grampians Police Service Arca which is almed at engaging recidivist households in an attempt to address family violence. Additionally, thore has been an inereased allocation of police resources in the St Arnaud area, and strategic work done (o develop steategies that address family violence,

Al. I was told that since 2002, considevable-etforts have been made by Victorla Police to ensure that the organisation responds ta reports of family violence and child abuse as serious {ncidents that watrant immediate police attention and n professional, well co-ordinated response, This commitment is reflected Jn documents such as the Code af Practice for the Investigation of Family Violence and Living Free from Violence - Upholding the Right: Victoria Police Strategy to Reduce Violence Against Women and Children 2009 ~ 2014, Publicly available crime statistics reflect that over the past five years, the number of family violence incidents police have attended has incteased considerably, and that there has been an associated rise in thé number of charges laid in comection to these matters,26 ;

42, The evidence presented at inquest however revenled that at the time of Hayley’s death, the expectations and cultural attitudes embodied in this reform had not been absorbed by the entire organisation, On more than one occasion and across a range of police units featuring both

26 “Victoria Police, Pantly Incident Reports 2006/07 « 2010/11, 2011, huipv/www police, vie. gov. au/contentasp7a=intormnetBridghngPagodeMedia_ID=72311

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junior -and long-standing members, it was demonstrated that a lack of clarity existed as to the, approptlate coutse of action to be pursued by Victoria Police in respect to a complaint of setious child abuse, :

43, L acknowledge the significant range of measutes that have since occutred to address flis issue, but emphasise that an ongoing and strategic approach 1s necessary in order that the requisite level of awareness and ptocedutal compliance take place both in the long term, T have therefors made two recommendations to address this matter (Recommendations | and 2),

Family violence and criminal offence

44, he police investigation regatding the presentation of Hayley's injuries and identification of those responsible was impeded in a number of ways, Evident was a premature foons by police ott the admissibility of evidence that might later be used in criminal proceedings,

45, The inquest heard that on at least two occasions, eatly judgements regarding the type of information that may, ot may not have been,. admissible in court, unnecessarily curtailed the investigative process, A thorough. criminal investigation clearly requites that information from 4 wide range of sources be collected und examined in the initial stages of this process, regardless of whether or not it can later be used in any court proceedings that may atise, ‘

A6, Victoria Police submitied that this 1s, and was, thelr policy, and that this approach underlies the teaining ‘and instruction of tts members, To this end, and for the purpose of placing this commitment on the public record, I note the stated intention on behalf of the Victoria Police to endeavour to ensure that the need to keep am open mind and perform any criminal investigation in a thorough and objective manner will be relnforced through continued professional development and training, ;

DEPARTMENT OF HUMAN SERVICES

47, The investigation of Hayley’s injurtes conducted by the DHS Child Protection service on 30 Fhe 2009 was found to be lacking in a number of ways, On this day, the significance of some of the issues initially flagged to the DHS Child Protection service in early February 2009 might have assumed greater significant, In addition, SM's disclosure relating to the cause of injuries to Hayley’s face was inudequately investigated,

48. ' Appyoptiate concessions were made by the DEIS in respect to their involvement in the investigation that was conducted on 30 June 200927 Primarily, 1b was acknowledged that relevant case-<notes were not recorded on the electronic Client Relationship Information System (CRIS) within the prescrlbed timeframes; and that a more thorough investigation of Hayley’s injuries should have occurred,

37 Submission on behalf of the Secretary to the Department of Homan Services dated 8 July 2011

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49, This might have involved a thorough visual examination at the very least, and most likely, a forensic medical examination, The Department stated that it would be usual practice for a thorough visual examination of Hayley to be undertaken, It is not the purpose of the inquest to assess this claim, but I do draw attention to fact the that on this oécasion, a very experienced.

practitioner with access to information about the family’s extensive involvement with the DES Child Protection service did not take this course of action, Nevertheless, further inquiries were

made with Robert sbout Hayley’s injuiles in a prompt manner by child protection workers on that:

day, Tt was agteed at the inquest that it would have also been beneficial for additional enquiries to be made with individual staff members of the St Amand's Children's Precinct as well as ‘SR,

50, 1 note that following Hayley's death, the Office of the Child Safety Commissioner . prepared a report that identified systom-wide issues relevant to her death, In a publicly released summary of some of the findings froma this investigation, staff vacancles and incteased workloads for employees in the Grampians region, were identified as being problematic at the time,28

Si, This point was also raised at the inquest, although it did not form a specific focus of the investigation, Nevertheless, {t was stated that the child protection worker who had responsibility for Hayley and her family had a case-load of between 50 and 70 cases throughout May and June 2009, Whilst this was not provided by DES as 9 justification for the ovents that occurred, it 1s nonetheless significant in terms of understanding some of the pressures faced by child protections workers during this period, It was reported that additional government funding was ditected to the DHS Child Protection service to adduess this situation, which resulted in eight new

positions in the Grampians child protection program and the introduction of additional senior

roles across the organisation to focus on supervisioti and skill development.29

52, A suite of training measures were also introduced by the DHS, both in the Grampians region and across the organisation at large, These included specialist training for supervisory staff and reflective practice sessions led by a senior Child Protection worker, Advanced practice in child protection training was also delivered in various regions In 2010 and 2011,

53, Hayley’s death also initlated some rovislon to the DHS Child Protection Practice Manual, particularly in rogatd to advice zegarding ‘Conducting the first visit.’ This update inchided practice standards and procedural constderatlons for planning and commencing an investigation, interviews with volevant parties, visual examination of the child and managing parental resistance when it occurs,

Sd, Lamake one final observation, On the occaston of the joint visit between the DHS Child Protection service and Victorla Police on 30 June 2009, there was an apparent lack of clavity in regard to, the expectations and requirements of protective interveners im response to the identification of Hayley’s injuries,

28 Departmont of Human Services, Government response to the review of the statewide Implications af the death of Hayley undertaken by the Office of the Child safely Canuuisstoner, 2009, Victorian Government, Department of Homan Services, httpif/www.dbs, vie.cov.au/about-the-departnent/news-urchlye/Parda4594

29 Statement of Melissa McInerney, DHS Gramplans Region, dated 25 November 2009

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55, During the inquest, reference was made to a protocol first developed in 1998 between the DHS and Victoria Police, that relates to improved provision and delivery of services to children and young people who have suffered, ot likely to suffer, significunt harm dus to physical, sexual, emotional ot psychological abuse and/or neglect, It was noted that this protocol is under review, however I would like to impress that particilar consideration be given to the need for improved clarity regarding the roles, responsibilities and required actions of both Victoria Police and the DHS Child Protection within this dognment, I have therefore made a recommendation to address this issue (Recommendation 3), .

COMMENTS ‘ ‘ : Pursuant to sectiot 67(3) of the Coroners Act 2008, I make the following cotiment(s) oomnected with the death:

Larly Identification and Intervention with vulnerable fanriHes

1. . ‘The Inquest identified two main areas with respect to early identifivation and intervention that were relevant to the elroumstances surrounding Hayley’s death, Firstly, there appears to have been, a lack of clarity as to whether ‘the isstes pextnining the cate of Hayley and Sean, prlor to their injuries emerging from May 2009, were best managed within a child protection framework ot under a family support model. : .

2, While it was appropriate that the DIS Child Protectlon service investigated concerms raised from eatly Febroary 2009, from this time onward, and np until the Department became aware of the possibility of child abuse having occurred, 1¢ would have been prudent for the Department to discuss family support options with Robest and give consideration to referring him to Child FIRST,

3, The court heard that the roles and tesponsibilities of DHS Child Protection and Child FIRST ave governed by the Child Protection and Integrated Family Services State-Wide Agveoment (‘Shell Agreement’) 2010, It is important that effective communication and information sharing between the two organisatlons occut, as intended by this agreement, so that " ‘netances of child abuse zequiting investigation take place promptly, and instances in which vulnerable families requiring intervention and support receive this assistance,

4, Following Hayley’s death, further funding for Child FIRST was made available to Child FIRST by the Victorian Government.2° ‘The court heard however, that these funds wore easily absorbed and that service demand currently excceds capacity, ‘This has reportedly resulted in ptoritisation of cases and tesultant waiting lists for services, as well as impacting upon the quality of services that can feasibly be delivered. These are reat and important considerations,

30 Departinent af ‘Human Services, Government response to the review of the statewlde inplicattons of the death of Hayley undertaken by the Office of the Child safety Commlsstoner, 2009, Victorian Government, Department of Haman Serylees, hitov/www.dhs, vlc, pov. qu/about-the-cepartment/news-archlyve/?a=434594

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5, It is beyond the tole of the coroner to argue for allocation of funding and resoutces for particular government and non-government initiatives, Nevertheless, it would appear necessary for a thorough analysis of existing service demand and unmet need to be conducted in order to fully comprehend the extent of the vequirements for family support and early intervention setvices in the Grampians region, I have therefore made a xecommendation which addresses this issue (Recommendation 4). ,

Complex social problems and the ability to parent

6, My investigation revealed a range of social problems that undoubtedly impreted on the degree to which parental responsibilities were met, These included a history of family violence, drug and alcohol use sustained over many years; parental leaning difficulties and low levels of literacy; unemployment, financial hardship and socio-economic disadvantage; generational involvement with the DHS Child Protection service; limited soclal and, informal support networks; and, a lack of connection to the local community.

1 Agalnst these complexities, itis clear that Robert required specific assistance with respect to his ability ‘to provide a stable and nurturing cnvizonment for his children, Evidence was presented to indicate that developmental milestones, age appropiate behaviours and suitable behaviour management techniques for young children wete concepts not well understood by Robert, Both in his parontal role and in respect to his personal difficulties, Robert undoubtedly requited a far gteator level of practical assistance, guidance, education and support, than he was receiving in the months preceding Hayley’s death,

8, ‘There ig some evidence to indicate that parental education and home visiting programs can play a role in a comprehensive approach to child maltreatment prevention.3!- Two examples of parenting support progtams operational in the Grampians region were disoussed at the inquest, These are the in-home family support service offered by Wimmera Unttlng Care and the PatentChild Mother Goose Program.32

Significance of injuries detected on children

9, Hayley's death was subject to examination by the Victorlan Child Death Review.

Committee (VCDRC)33 Ih May 2010, several recommendations were made by the VCDRC to the DHS arising from this analysis. ‘These were summarised and tendered at the inquest by the DUS, Two of these recommendations addressed issues pertaining to clacity around program.

guidance concemnlng phystcal abuso aud the conditions for attanging a medical examination in

AT See for exnmole, P.J Holzer ot al, ‘The effectiveness of parent education and home visiting chiid mattreatment prevention programs’, Child Abuse Prevention Issttes no, 24, Australien Trotitute of Family Studies Nattoral Chikt Proteétlon. Clearinghouse, Melbourne Australia 2006, :

32 ‘The Parent-Child Mather Goose Program aims to strengthen the bond between patent child through the use of rhymes, songs and stories,

35 "The Victorlan Child Death Review Commalttee (YCDRC) reviows the deaths of children and young people who were olients of the Victorlan Child Protectlon service at tine of iheir dealt or within 12 months of their death, The gitn of the VCDIRC is to identify common themes and comment on service responses fo vulnerable children and (helr tamittes, ‘

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cages of alleged physical abuse of young children, The DHS states that it has zesponded to these recommendations, oe

10. Many childven who die as a vesult of fatal assault have a documented history of prior injuries, including bruising and fractures.34 Whilo bruising 4s a relatively common childhood injucy, teseatch indicates that bruising détected on certain regions of the body should be treated with particular caution and prompt further investigation, For example, brulsing observed on a child’s ‘head, neck, ears, tank, buttocks and genital region has been shown to be mote indicative of inflicted injuries.35 Recognition of the significance of bruising and other injuries in these areas is irhportant in order to better identify cases of suspected child abuse.

11. A number of professtonals who had contact with Hayley and 8M from mid-May 2009 did not appear to fully appreciate the significance of the location of the bruising and other injuries observed on the children in the weeks preceding her severe assault. ,

12, — Both Victoria Police and the DHS Child Protection service have since taken further steps in an effort to.ensure that a thorough visual examination ot forensic medical investigation occurs, However, it is equally impottant that the significance of the location of particular injuries upon children be zoalised, particularly by protective interveners, so that sighting such injucies prompts, and even closer analysis, and adds mote weight for tho need for a thorough visual examination or forénsle medical investigation as tequired.36 I have therefore made a recommendation to addvess this issue (Recommendation 5).

Tntormation sharing

13, In fhe weeks precoding Hayley’s death, professional petsous, held important information about the welfwte and living circumstances of Hayley and her brother. ‘This included both historical and contemporary knowledge, collected from a variely of sources, The inquest heard that on a number of occasions, this information was not commmnicated to the appropriate person ina Umely and complete manner, This issue ocoutred both within and between organisations,

i4, It is tecognised that for the most part, there was no deliberate attempt for this situation to atise, Rather; certain observations and knowledge held by a range of partios appears to have been either Inconrectly assessed or assigned a lesser leves of significance than it required, As a result, the apparent deterioration in the oare provided to Hayley and the increased risks both she and her brother faced do not appear to have been fully appreciated by those in a position to take action,

34 sw Commission for Children and Young People, Fatal Assault of Children and Young People, (2002) 66,

38 BAD, Dunstan et al, ‘A scoring system for brulse paltettis; 4 tool for identlfying abuse’ (2002) 86 Archives of Disectses tn Childhood 330-393;'‘Tomika Harris, ‘Benlses in children: Normal or child abuse?’ (2010) 24 (4) Jornal of Pediatrie Health Care 216-221; 8 Maguire ot ul, ‘Ave there patterns of bralsing In childhood which are dingnostic of suggostive of abuse? A systematic review’ (2004) 90 Archives af ‘Disease In Childhood 182-186, M. Clyde Plerce ot al, ‘Bruising chatacterlstios discriminating physical chltd abuse from acoldental trauma’, (2010) 125 (67) Pediaivies 67-74,

36 ‘This 4s not to underosthnate (he importance of other sites of Injury detected upon children, but rather fo deaw attention fo the Hteraince highlighting the significance of partloylur locatlons as move Indicative of abuse,

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15, Several examples of this kind were Identified and discussed during the ‘course of the coronial investigation, These are brlefly listed here, not for the purpose of attributing blame, but to demonstrate that fatal assaults of young children rarely occur ‘out of thé blog,’ Rather, it is often the case that significant information regarding parental risk factors and/or a deterioration in the child’s living circumstances has not been fully in veraed

° As outlined above, Robert would have benefited ‘from eatly referral to Child FIRST by the DHS Child Protection servico, Both Robort and CG were well known to the Department, and consideration of thelz histories would suggest that ongoing assistance was likely to have been necessary throughout the catly years of their children’s lives, However, an early referral was

; not forthcoming by the DHS,

-@ From mid-May 2009, childcare workers had documentéd their observations and. conesens for Hayley and SM. Within the childcare centre itself, there appears to have been some level of disngreement as to the causation and significance of these injuries on at least one occasion,

‘While the St Arnaud Children’s contre acted appropriately in notifying the DHS Child

Protection of theit concerns, fhe detatl that was subsequently commenicated at this time remains in dispute,

e It is the position of the DHS Child Protection service and Victoria Police that on the occasion of their visit to the centre on 30 Tune 2009, all records pertaining to problems identified with the children were not revealed, Importantly however, this information was not requested, and the onns is upon protective interveners to make inquiries about such information,

o Furthermore, during the course of the investigation into Hayley’s assault from 8 July 2009, cominnnication of information already in possession by Victoria Police between CI and SOCAU did not take place, Further, communication between Victorla Police and the DHS Child Protection service at the time Hayley’s fe threatening injures were reported did not happen at the first opportunity, As outlined, this had implications for the investigation that followed,

16, Provisions currently exist for concems regarding the welfare and safety of a child to be: shared between, and with, ptotectlve Intetveneis, A lack of legislative or governance arrangements was not at fault heve, Rather, the problom sested with a failuze among individuals and organisations to fully disclose both the presence end detail of information that was held, and to confidently state a position as to the perceived significant of this information, In tutn, this resulted In the absence of a complete pictwvo having been available, and perhaps, for more desisive protective action to be implemented,

17, A range of initiatives have been introduced following Hayley’s death to help improve communication and information sharing among otganisations working with children at risk and vulnerable families in the Grampians region. The court heard that for the most part, these share the common objective of building relationships betwen organisations; enhancing understanding of the roles and responsibilities of respective service providers; and improving understanding of regional issucs impacting upon vulnerable children and their familles.

18: Efforts in this sogard have included introduction of formal meetings on a three monthly basis between Victoria Police SOCIT and DHS Child Protection service in ILorsham, and the

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development of the Northern Grampians Vulnerable Children Network comprised of the DHS Manager of Community Care and Housing, the Depattment of Education and Early Child Development (DHECD) Harly Years Manager, the Manager of Wimmera Uniting Care, the Noxthern Grampians Shire Council and Victoria Police.

19. Further, in June 2010, Victoria Police and the DHS signed an overarching Memorandum of Understanding (MOU) with regard to general principles of cooperatton on a range of issues, Accompanying the MOU was the introduction of a governance process whereby the Secretary of

DHS, the Chief Commissioner of Victoria Police and their relevant Executive Directors and.

Deputies meet biannually to discuss issues emerging from cooperation between the two organisations. ‘This group has also given consideration to how the principles of cooperation in any agreement can be implemented and managed at a regional level.

20, My final observation here 1s that the success ‘of these initiatives in meeting the underlying objective of improved cooperation and communication among organisations involved in ‘the prevention, identification, and vesponse to child maltreatment, will require an ongoing commitment across all levels of the respective organisations, ‘

Community participation in the protection of children

21, The safety and protection of children is ah activity that must be shared by the entire community, The circumstances suutounding Hayley’s death indicate the need for persons who hold concerns for children and young people to communicate their observations in a clear and complete manner as soon as possible, und patticulacty, to those who ato in a position to intervene,

22; “Commmnity. awareness and involvement ate important aspects of initiatives aimed at ptevouting child maltveatment and abuse, Indeed, the extent to which those efforts are effective and sustainable often depends on the level of community participation, During thls investigation, a numbor of those who gave evidence attested to the widely held view that the prevention of child abuse and neglect is a shared responsibility that involves co-operation among services providers, professionals, local or ganisations and individyal community members, It was further domonstrated that those from the local ata held valuable knowledge about the particular Issues encountered by families in the region, Many wete cognisant of the obstacles faced by Robert and the extent to which they impacted upon his ability to care for his children,

23, Thote is a cleat role for professionals to wotk actively tn ‘theit local areas to raise awareness and develop understanding. around the factors that pose risks to childven as well as child abuse itself, Conceivably, this should involve activities designed to increase knowledge of how assistance can be obtained for families experiencing difficulty, as well as the roles and responsibilitles of relevant organisations in fhe local avea. Importantly, this should promote a degree of visibility and stvengthen the relationship between services and local commutity members, [have therefore made a recommendation to addvoss this issue (Recommendation 6),

Protecting Victoria’s Vulnerable Children Inquiry

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24, On 31 January 2011, the Victorlan Government announced the ‘Protecting Victoria’s Vulnerable Children’ Inquiry. The purpose of the Inquiry is to investigate systemic problems in Victorla’s child protection system and make recommendations to strengthen. the protection of Victorian children who are at tisk of, ot who have experienced, neglect and/or abuse. The terms of reference that apply to the Inquiry are broad, but include consideration being given to the factors that increase the risk of abuse or neglect occuring; and the interaction of departments and service providers in thelr work with at-risk families and childven,

25, Many of the issues touched upon as part of the inquest are pertinent to this Inquiry. These issues ate complex and not easily addressed through a cosontal investigation alone. Nevertheless, thoy are highly relevant in respect to a broader investigation into child welfare and safety in this state, : :

I therefore direct that_a de-identified copy of this finding be provided to the Protecting Victoria's Vulnerable Children Inguiry for information purposes only,

Previous revlows of Victorla’s child protection system

26. The Victotlan child protection jurisdiction has been reviewed many times, Prior to the.

cutrent teylow noted above, the Victorian Law Refortn Commission yoleased Its Final Report into Protection Applications in the Children’s Court (the VLRC Report) in June 2010, The VLRC Report noted that there had been nine major reviews in the past 33 years and concluded that a major review ocurred every four to five years, supplemented by a smaller review approximately every second yeat, In addition, tt noted that the ‘prevalence of reviews demonstrates both the complexity of child protection issues and the difficulty in gaining widespread support for yeform,’ .

• 27, Options proposed in the VLRC Report included the establishment of an Office of the Children and Youth Advocate as multi-disciplinary body to advance the intetests of children and young petsons as- well as an option to broaden the role of the Child Safety Commissioner, At inquest, I heard evidence from an experienced. child protection worker who strongly advocated - for the establishment of a ministry for children in Victoria - ‘where there are free and universal services .,, for every child’, Whilst a recommendation of this kind is outside the scope of this investigation, there is no doubt that an independent body to the protect the interests of childyen would be a worthwhile and much needed advancement.

The Victorian Systemic Review of Family Violence Deaths

28, The deaths of Hayley and Robext were examined as part of the Victoria Systemlo Review of Family Violence Deaths (VSREVD), The VSRFVD, based with the Coroners Court of Victoria, provides analysts of family violence-related deaths investigated by Victorian coroners to inform future interventions aimed at protecting childven. and adulis from violence. .I am gtateful for the assistance provided to me by the YSRFVD throughout the course of this coronal investigation.

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RECOMMENDATIONS Pursuant to sectlon 72(2) of the Coroners Act 2008, T mnaike the following, recommendations cotuhected with the death: .

L That Victoria Police give consideration to developing a program of zegular training and information disseminatlon for opetational members across all regions of the orgatisation to ensure familiavity and compliance with the Code of Practice for the Investigation of Family Violence, the Victoria Polloo Manual portalning to the investigation and response to family violence, and completion of the Victorla Police Form L17, in order to ensure that requirements of members ate woll understood, and that appropriate action {s taken when police receive reports of, and respond to, instances of family violence and child abuse,

2, That all Victoria Police officers be provided with the contact details of DHS Child Protection services in each tegion and the Child Protection After Hours Emergency Service, and be reminded that, putsuant to sectlon 181 of the Children, Youth and Families Act 2005 (¥ ie), all members, not only SOCIT officers, are protective interyeners and mandatory reporters,

3, That the 1998 protocol between Victoria Police and DHS, Protecting Children’ Protocol Between the Department of Human Services and Victoria Police, be revised and updated to teflect the current legislative requirements of both organisations, and clarify the roles and responsibilities of both the Department of Human Services and Victorta’ Police, in respect to investigations of child abuse,

4, That DIS give consideration to conducting a thorough analysis of early intervention and family support zequirements in the Grampians region, ‘This shoyld include consideration of unmet - need, client waiting lists and proportional staff ratios to client populations, in order to determine the capacity of the region to effectively respond to these requirements, and enable a timely and planned approach to the delivery of casly intervention and family support services in this area,

3. That DHS Child Protection service and Victoria Police consider providing specific taining and/or Information to staff members involved in the investigation of child abuse, regarding the significance of bruising and injury patterns that may be indicative of inflicted injuries upon children, in order to afford particular significance to these injuries both at the time of notification and when conducting furthor investigation,

6, That DHS Child Protection, Child FIRST and Victoria Police SOCIT in the Grampians region give consideration to engaging in-a systematic program of community education (targeting childcare centres, schools and other community groups), regarding the risk factors for, and identification of, possible child abuse arid neglect, including an educative component as to when a notification to the DHS Child protection ts watranted, in order to facilitate greater community

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awareness of these issues dnd promote the visibility of services that are able to assist childven either at risk of, exposed to, such violence and abuse. .

Signature:

John O Coroner Date: 19th/Ochdber, 2011

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