NSW coroner issues findings after inquest into death of five-year-old at mother’s hands

A New South Wales coroner has issued 17 recommendations after an inquest into the drowning death of a five-year-old boy at the hands of his mother.

The inquest looked into the dealings the family had with authorities and agencies over the months leading to the Moama incident 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 judge found she suffered from multiple psychiatric disorders and had a delusional belief that she had to drown the boy and his brother – who survived the incident – in order to protect them.

The ensuing inquest heard that the boys’ grandmother had been their primary carer for at least 18 months prior to the incident and had made several attempts to formalize this arrangement.

The Department of Family and Community Services had received seven reports over 14 months indicating that the children were at risk of abuse by their mothers.

While the boys were deemed by social workers to be at “high risk” in their mother’s care due to drug use and violent behavior, 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 locations in Victoria.

After lying awake waiting for them to come home, the grandmother signaled police on the street in the early hours of the next morning.

Officers present did not file a welfare concern report.

Subsequent reports to police and triple-0 later in the day, including by a social worker, did not raise 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 fled.

It took nearly two days for police divers to find the boy’s body.(Provided: Rusty Woodger/Riverine Herald)

Magistrate Teresa O’Sullivan said he was a ‘beloved younger brother’ who ‘enjoyed playing games and going to the park’.

“[He] always carried a truck and a ball,” she said.

“The heartache of [his] the loss continues to be felt by [his] family and the wider Deniliquin community.”

The boy’s grandmother listened via video link to the delivery of the results.

A building with high bay windows.
The findings of the coroner’s inquest have been delivered to the NSW Coroners Court. (ABC Riverina: Romy Stephens)

Police failure to examine ‘trouble’

Magistrate O’Sullivan directed her recommendations to individuals and groups, including the NSW and Victoria Police Commissioners, the Department of Communities and Justice, Murrumbidgee Local Health District (MLHD) and the Office of Catholic teaching.

In her findings, she noted that police forces in New South Wales and Victoria “did not” take the information they received about the children seriously and that the two agencies “did not not” conducted an adequate review of their response to the incident.

Regarding Victoria Police, Magistrate O’Sullivan found the lack of scrutiny and acceptance that no lesson could be learned “disturbing” and “regrettable”.

She said the response “deserved further consideration by the Victoria Police Executive with a view to examining why such a review has not taken place… and to ensure that, in appropriate circumstances, the reviews are conducted in a timely manner with an appropriate level of rigor.”.

She recommended that the NSW Police Commissioner put more emphasis on the analysis of missing persons reports and that the incident be used as a case study to highlight the importance of registering children as people with need for protection, if any.

In a statement, NSW Police said a full review of the findings was underway and all recommendations to police were being considered.

Magistrate O’Sullivan also recommended that Department of Communities and Justice (DJC) staff receive training on the steps that could be taken if an at-risk child is removed from their usual place of residence, including how to how to communicate this information to the police.

In a statement, a spokesperson said the DCJ was committed to protecting vulnerable children and would consider all recommendations from the coroner.

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