A New South Wales coroner has handed down 17 recommendations after an inquest into the drowning death of a five-year-old boy at the hands of his mother.
The inquest examined the dealings the family had with authorities and agencies in the months leading up to the incident at Moama, on the NSW-Victorian border, in 2017.
The boy's mother, who cannot be named for legal reasons, was found not guilty of murder on mental health grounds in 2018.
A Supreme Court justice found she suffered from multiple psychiatric conditions and held a delusional belief that she had to drown the boy and his brother – who survived the incident – in order to protect them.
The subsequent inquest heard how the boys' grandmother had been their primary carer for at least 18 months leading up to the incident and that she had made multiple attempts to formalise that arrangement.
The Department of Family and Community Services had received seven reports over 14 months that the children were at risk of harm from their mother.
While the boys were considered by caseworkers to be at "high risk" in their mother's care due to drug taking and violent behaviour, she remained their legal parent.
The mother took the boys from their Deniliquin home for an outing on March 1, 2017 – the day before the tragic incident – and then took them to various places in Victoria.
After lying awake waiting for them to come home, the grandmother flagged down police officers on the street in the early hours the next morning.
The attending officers did not lodge a concern-for-welfare report.
Subsequent reports to police and triple-0 later that day, including by a caseworker, did not trigger immediate concerns for the welfare of the children.
The five-year-old drowned in the Murray River at 6:15pm on March 2, 2017.
His older brother escaped but was attacked by a dog that lived on the property as he ran away.
Magistrate Teresa O'Sullivan said he was a "much loved younger brother" who "loved to play games and attend the park".
"[He] always carried a truck and a ball," she said.
"The heartache of [his] loss continues to be felt by [his] family and the wider Deniliquin community."
The boy's grandmother listened via video link as the findings were delivered.
Police failure to review 'troubling'
Magistrate O'Sullivan directed her recommendations at individuals and groups, including Police Commissioners for NSW and Victoria, the Department of Communities and Justice, the Murrumbidgee Local Health District (MLHD) and the Catholic Education Office.
In her findings she noted that both the NSW and Victorian police forces "failed" to give due seriousness to reports they received relating to the children and that both agencies "failed" to conduct an adequate review into their response to the incident.
In relation to Victoria Police, Magistrate O'Sullivan found the lack of a review and acceptance that no lessons could be learned "troubling" and "regrettable".
She said the response "warrants further consideration by the executive of the Victoria Police force with a view to considering why such a review did not occur … and to ensure that in appropriate circumstances, reviews are conducted in a timely fashion with a suitable level of rigour".
She recommended the NSW Police Commissioner place greater emphasis on the analysis of missing persons reports and that the incident be used as a case study to emphasise the importance of listing children as persons in need of protection where appropriate.
In a statement, NSW Police said a comprehensive review of the findings was underway and all recommendations directed to police are being considered.
Magistrate O'Sullivan also recommended that Department of Communities and Justice (DJC) staff receive training around steps that could be taken if an at-risk child was removed from their usual place of residence, including how to communicate that information to police.
In a statement, a spokesperson said the DCJ was committed to protecting vulnerable children and would consider any recommendations made by the coroner.
