Last updated 20 January 2022

The coroner may investigate the death of a child where there are concerns about a family’s contact with the child protection system, especially if there may have been a missed opportunity for protective intervention. Sadly, child deaths may arise because of domestic and family violence, neglect or self-harm. An inquest can help to further the community’s understanding of the risks faced by children in care, including as they relate to health, housing, education, child protection and police, and help to inform broader system-wide improvement.

In any case where a child dies after being involved with a relevant agency (e.g. Department of Children, Youth Justice and Multicultural Affairs, QPS, Education Queensland, Queensland Health), the compulsory child death review process will commence (ch 7A Child Protection Act 1999 (Qld) (Child Protection Act)). Initially, the chief executive will investigate whether the child was known to the department within 12 months of their death (s 245E Child Protection Act). This report will be provided to the Child Death Review Board as well as the investigating coroner via the state coroner, and will help narrow the issues requiring investigation (ss 245N(1), 245P Child Protection Act).

If it becomes evident that the department’s involvement with the child or their family is outside of the 12-month timeframe, the coroner may seek the approval of the Minister for Children, Youth Justice and Multicultural Affairs to undertake a child-death review (s 245F Child Protection Act).

If the child death review does not address the issues required for the coronial investigation, the coroner may obtain:

  • the child’s departmental case file
  • statements from departmental or third-party service-provider staff (e.g. those who provide support to foster parents) in relation to the management of the child’s case
  • any relevant departmental policies and procedures
  • a statement from a senior departmental officer about the extent to which the child death review recommendations have been addressed or implemented
  • an independent expert review of the child’s management, with the state coroner’s permission.

The Domestic and Family Violence Death Review and Advisory Board is also able to support the coroner in relation to the systemic issues in child protection (ss 91A, 91D Coroners Act 2003 (Qld)).

Case Study: Mason Lee

On 11 June 2016, Mason Lee (22 months old) died of abdominal injuries inflicted by his mother’s boyfriend William O’Sullivan. An autopsy showed that Mason had been severely abused by O’Sullivan in the days leading up to his death.

Many agencies appeared at the inquest, including the Department of Child Safety, Youth and Women (now the Department of Children, Youth Justice and Multi-cultural Affairs), Queensland Corrective Services, the Commissioner of Police and the Department of Health. Both O’Sullivan and Mason’s mother did not attend at the inquest as they were serving jail time for manslaughter and cruelty.

The inquest found that although the department was aware that Mason was an abuse victim, it did not take sufficient action to protect him. The coroner found that a number of the department’s employees failed to carry out their duties (see Inquest into the death of Mason Jet Lee (2010) COR 2857/04(9)).

Prior to the coroner’s findings being handed down, the government enacted significant reforms to child safety. The coroner also made a number of recommendations all of which were adopted by the government.