Demographics
15y, female
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2020-01-14
Finding date
2025-03-03
Cause of death
hanging
AI-generated summary
Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed cases due to "competing priorities" despite clear risks; breached Family Court orders preventing contact with her abusive mother and Nathan were known but ignored for years; school suspensions (particularly a 20-day suspension ending mid-term break) contributed to prolonged disengagement without adequate support or alternative arrangements; and critical opportunities to provide concrete support (discharge from hospital, placement breakdowns, homelessness) were missed. No suitable suspension alternatives existed for vulnerable girls. DCJ failed to adequately support informal carers (Rachel) or invoke legislative powers to ensure permanency. The coroner emphasised that vulnerable adolescents like Harmony need concrete support despite being "difficult to engage," and that resource constraints cannot justify closing cases with identified significant harm.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Harmony Hearing dates: 30 September 2024 – 4 October 2024 Date of findings: 3 March 2025 Place of findings: Coroners Court of NSW, Lidcombe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – intentionally self-inflicted death; death of a young person; family violence and neglect – family known to the NSW Department of Communities and Justice; educational neglect; systemic response to homelessness, abuse and neglect of a minor; recommendations.
File Number: 2020/0014031
Representation:
Ms Gillian Mahony SC, instructed by Ms Kathleen McKinlay and Ms Alexis McShane of the Department of Communities and Justice, Legal
Ms Emma Sullivan, instructed by Ms Stephanie Young of DCJ, formerly the Department of Family and Community Services
Ms Jeunesse Chapman, instructed by Ms Jordan Power of the Crown Solicitor’s Office for the NSW Department of Education
Ms Kim Burke, instructed by Mr Stuart Robinson of the NSW Police Force Non publication orders: Non-publication orders made on 30 September 2024 prohibit the publication of any information that identifies the deceased, their family members, specified community members and the names of relevant teachers, students and schools.
Non-publication orders made on 4 October 2024 prohibit the publication of the DCJ Internal Child Death Review report and the draft Home School Liaison Program Evaluation Report.
I have given specific consideration to the operation of section 75 Coroners Act 2009 and find that it is in the public interest to allow the publication of this report.
A copy of the orders can be obtained on application to the Coroners Court registry.
Findings Identity The person who died was Harmony.
Date of death Harmony died on 14 January 2020.
Place of death Harmony died in the bathroom of room 26, Cundle Motor Lodge, Cundletown NSW.
Cause of death Harmony died by hanging.
Manner of death Her death was self-inflicted in circumstances of longstanding neglect, family violence and disengagement from school.
Recommendations To the Department of Communities and Justice
referrals and information regardless of whether the person is a parent, or a family or community member who is caring for a child to whom they do not hold parental responsibility.
To the Department of Education (DoE)
That DoE consider prioritising the redesign of the HSLP as a matter of urgency, taking into account the Home School Liaison Program Draft Report and the findings of this inquest.
That the DoE review its current suspension policy as to whether it adequately addresses the needs of children and young people experiencing abuse, neglect and homelessness, including the need for suspensions to be carried out in places external to the home environment when that environment presents a risk.
That DoE give consideration to amending the suspension policy to mandate consideration of the impact of school holidays when setting a suspension period. Particular consideration should be given to using the commencement of a new term as a reset wherever possible.
Where a student subject to a suspension is not in the care of the person who holds parental responsibility and is subject to an out of school suspension, procedures be developed to address, inter alia: a. To whom the school is to issue mandatory correspondence b. Whether the expectation of engagement by the parent or carer who the student would otherwise have resided with continues, and if not, who is responsible for engaging with the student during the period of the suspension.
That the DoE consider using Harmony’s experience as a case study for the training of DoE staff on the impact of suspension on school connectedness.
Table of Contents
Introduction
Harmony was only a teenager when she died in a motel bathroom. Her death was intentionally self-inflicted.
Harmony has been described as charismatic, strong and affectionate by those who loved her. She was a good friend, and much loved by her parents, grandparents, and carers.
When Harmony was younger, she enjoyed playing outside with her sibling and cousins.
Later in life, she became interested in hair, make-up, and beauty and even undertook work experience with a local beautician. Rachel and her daughter, Olga, told the Court that Harmony had a warm, infectious smile and a beautiful heart and soul. She was caring, empathetic, and strong. Harmony had endured many difficulties in her short life, but it is important to remember that there were also times when she seemed to believe that there was a real possibility for a better future.
These coronial proceedings took place out of a deep respect for Harmony’s life and a refusal to accept the inevitability of her untimely death. The despair she must have felt and the reasons for it must be carefully scrutinised and properly understood. No young person should feel so alone and so totally without hope.
I acknowledge the presence of Harmony’s parents at this inquest and thank them for attending. Their participation in these difficult proceedings included facing their own challenges in being able to keep Harmony safe and it undoubtedly called for great courage.
Their pain and grief were palpable in the Court room. While their struggles were laid bare in open Court, I never doubted the great love they had for their daughter. It is clear that Harmony’s parents needed much greater support and guidance than they received as they tried to raise a daughter when they were themselves frequently struggling to survive.
The Court acknowledges that there were people who did their best to assist Harmony, including members of her extended family and school community. Present in Court were Rachel and her daughter, who were great friends to Harmony and who tried as best they could to keep her safe. Their kindness and care were evident and they have my deep respect.
I have no doubt that many others in the community were also affected by Harmony’s death, including her teachers and the care and refuge workers with whom she had contact.
It is important to remember that coronial proceedings are not about blame and it is worth noting at the outset that the legal representatives for both the Department of Communities and Justice (DCJ)1 and the Department of Education (DoE) approached these proceedings with openness and integrity on behalf of their clients.
By the time these proceedings had commenced, DCJ had already undertaken a comprehensive and fearless review of its failings. The Internal Child Death Review (ICDR) conducted in September 2021 by the Serious Case Review Team was clearly a robust process which aimed to critically analyse DCJ’s involvement with Harmony and her family in order to identify anything that might improve departmental practice in the future. This inquest was not called to duplicate that work and instead aimed to focus on the issues which might remain for consideration after the internal review process was complete. The Court was assisted in this task by the frank evidence given by Belinda Edwards, Executive District Director, Hunter and Central Coast, DCJ. She shared her insights and an overview of Harmony’s interaction with DCJ. She was also able to speak to the changes that were made following the ICDR report.
The Department of Education (DoE) also assisted the Court by providing its draft report in relation to an evaluation of the Home School Liaison Program and by openly engaging with the issues raised.
Both Departments stressed the need to consider the issues facing Harmony from a holistic approach.
The role of the coroner and the scope of the inquest
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.2 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.3
This was not a mandatory inquest. While the time, place and medical cause of Harmony’s death was disclosed on the documentary evidence, the Court felt compelled to better understand the broader circumstances or manner of Harmony’s death. It was also 1 Formerly known as the Department of Family and Community Services (FACS). The Department will be referred to as DCJ throughout these findings for ease of reference.
2 Section 81 Coroners Act 2009 (NSW).
3 Section 82 Coroners Act 2009 (NSW).
appropriate to ask the agencies involved whether there is anything else we can do, as a community, to reduce the prospect of another young person taking their own life in like circumstances.
These proceedings took place a considerable time after Harmony’s death. They were delayed firstly by COVID-19 but also by resource limitations at this Court. I acknowledge that delay has the capacity to complicate the grief process for family and friends and to weaken the death prevention function of this Court. It is regrettable.
A list of issues was prepared before the proceedings commenced. These issues guided the investigation and I intend to structure these reasons by reference to the matters set out below: As to cause and manner of death
If Harmony died by suicide, what factors led to Harmony taking that action.
Did Harmony prepare a suicide note prior to her death, and if so, where is that note and what were its contents.
As relevant to DCJ
b. Is there and/or should there be a process in place where DCJ has power to make enquiries of the FCFCOA under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998 (the Care Act), or by other means, as to non-contact orders for children?
January 2015 and 14 January 2020: a. Was the review and response of DCJ to the reports made about Harmony appropriate; b. Were the interactions between Harmony, Susan, Nathan and other members of Harmony’s extended family adequately monitored and responded to; c. Were appropriate steps taken to ascertain whether there was any person available to provide out-of-home care for Harmony.
As relevant to NSWPF
Was NSW Police Force aware that Harmony was residing with Susan and Nathan contrary to orders of the FCFCOA, and if so, a. How did NSW Police come to hold that knowledge; b. What steps, if any, did that take in response to that information; c. Why did NSW Police facilitate the return of Harmony to Susan and Nathan’s care on or about 25 October 2019.
Did the NSWPF adequately respond to and investigate reports made to them by Harmony and others that Harmony was at risk whilst living with her biological mother and Nathan?
Could processes between NSWPF and DCJ be improved to assist police in identifying and reporting on children and young people at risk of serious harm and / or neglect?
As relevant to the DoE
respond to allegations of neglect of, abuse and violence against Harmony?
Was the decision of the DoE to not prioritise Harmony’s access to the formal Home School Liaison program appropriate in the circumstances?
Do the DoE’s behaviour management policies appropriately consider the impact of suspension on children with a known history of family domestic violence?
The evidence
The Court took evidence over five hearing days. The Court also received extensive documentary material in six volumes of evidence. This material included witness statements, medical and school records, photographs and CCTV, policies and procedures.
The Court also received expert evidence from Professor Linda Graham, Director of the Centre for Inclusive Education at Queensland University of Technology (QUT). Professor Graham has a PhD in Education and significant expertise in accessible learning and inclusive education practices. She has also led research into the overrepresentation of marginalised students in school suspension decisions.
While I am unable to refer specifically to all the available material in detail in my reasons, it has been comprehensively reviewed and assessed.
Background and brief chronology
Prior to the commencement of proceedings, those assisting me drafted a chronological summary from the available documentary evidence. The parties agreed that this document4, which was marked as an aide memoire, contained an accurate summary of the chronological events. I attach a copy of that document as an annexure to these reasons and do not intend to repeat all the material contained in it or analyse each interaction between Harmony and the agencies in her life. I adopt its content as an accurate summary of material before this Court. It provides the necessary background to some of the specific events examined below.
Counsel assisting also produced comprehensive submissions summarising much of the oral evidence. I have also relied heavily upon her document in recording my written reasons, at times adopting aspects of her summary.
4 Annexure 1 to these findings.
Background
Harmony was born on 7 May 2004 to Susan and Richard. Harmony had one older brother, Alex.
Harmony’s childhood was frequently chaotic and at times traumatic. While there were periods of relative calm, her family were unable to offer the continued stability a child requires. Parental substance use, homelessness and financial deprivation as well as interpersonal violence frequently threatened the peace which was sometimes achieved.
On 14 January 2020, Harmony died in room 26 of the Cundle Motor Lodge approximately 8 km from Taree. She had been staying at the motel with her mother Susan and her mother’s then partner, Nathan. Harmony was 15 years and eight months of age.
Both Harmony and her mother had at times been subject to Nathan’s violence. There were times when Harmony had escaped and slept in parks to avoid it. Their accommodation was unsuitable and unsafe.
The path to that motel room commenced in childhood. Harmony was about seven months old when she came to the attention of DCJ. Her parents struggled with substance use and family violence. Their accommodation was precarious and often substandard. When they split up, their separation was acrimonious and Susan’s new partner, Nathan, was abusive.
When Richard lapsed back into drug use in 2015, Harmony and her brother moved between family members. Not surprisingly, Harmony’s school engagement and learning was seriously affected. Many of the important events in her care and educational history are summarised in the chronology attached to these reasons and I do not intend to repeat them all here. However, a close understanding of that detailed chronology is necessary to understand the cumulative and growing risks which faced Harmony over the last chaotic four years of her life.
Events leading up to Harmony’s death
Harmony was staying with Susan and Nathan on the night of her death. The Court viewed CCTV footage taken from Manning Valley Anglican College, which is adjacent to the Cundle Motor Lodge. It depicted Susan and Nathan departing the motel at 1:23 AM (on 14 January 2020) in a vehicle and returning at 1:43 AM. Other CCTV footage places Susan and Nathan at a CBA ATM at 1:31 AM and at the United Service Station, Victoria Street, Taree at 1:35 AM. This objective evidence roughly matches Susan and Nathan’s account of their movements in the early hours of 14 January 2020.
Upon their return, Susan states that they were aware that Harmony was in the bathroom for a short period of time. Susan states she heard a loud bang in the bathroom. They called out to Harmony, who did not answer. The bathroom door was locked from the inside and Nathan apparently used a butter knife to open the door when she did not respond. Susan and Nathan reported that on opening the door they found Harmony hanging in the shower cubicle. Nathan cut her down and commenced CPR at 2:27 AM, while Susan called 000.
Paramedics stationed at Taree took the 000 call at 2:31 AM and were en route by 2:38 AM. There was no delay and an ambulance crew arrived at the motel at 2:41 AM.
Approximately 40 minutes had passed from the time Susan and Nathan returned to the motel to the making of the 000 call.
Paramedics entered the bathroom and found where Harmony was lying. They saw a rope underneath Harmony’s neck. They identified a deep ligature mark and described Harmony’s lips as blue in colour, with “mottled lividity” around her eye socket. A defibrillator and life pack were applied to Harmony but there was no sign of breathing and no response.
Her pupils were fixed and dilated with no reaction to light.
Post mortem investigations
A post-mortem examination was conducted by forensic pathologist Dr Lorraine Du Toit Prinsloo on 21 January 2020. She noted that a near circumferential ligature abrasion mark was present around Harmony’s neck and there was a small area of haemorrhage which measured less than one cm in diameter in the proximal aspect of the left sternocleidomastoid muscle at the attachment of the mastoid. I accept her medical opinion that the findings were in keeping with death by hanging.
No alcohol was detected in Harmony’s blood. Metabolites of cannabis were present in Harmony’s blood sample. I accept the forensic pathologist’s opinion that toxicology did not contribute to the cause of Harmony’s death.
The Issues
Prior to addressing the issues, it is firstly necessary to make clear that I accept that individual DCJ caseworkers and public school teachers operate under very difficult resourcing restraints.
Ms Edwards explained the difficulty her DCJ staff face on a daily basis. She stated that in her area they were only able to “go out to approximately 30-35% [of Risk of significant harm (ROSH) reports].” This means that a large number of serious matters are being closed without further information or direct contact and staff are required to prioritise and allocate in the most difficult of circumstances. She described the resulting high workers compensation costs for staff tasked to make these difficult decisions. I accept her evidence.
Public school teachers are also working under the most difficult of conditions. Teacher 8, principal of School 4, told the Court that a significant number of students in the catchment area for that school were subject to domestic violence, homelessness, living in refuges, or were subject to orders placing them in out-of-home care. When asked to comment on school based suspension centres, Teacher 6, principal of School 4, spoke of resourcing issues and told the Court ‘these type of things would be wonderful but it’s in the practicalities unfortunately… these things don’t exist.” Evidence was also presented on the difficulties of attracting and retaining school counsellors, so crucial in supporting students and teachers with wellbeing issues. DoE Deputy Secretary Martin Graham observed that having a counsellor available on staff was a real issue for regional and rural schools in particular. I accept without reservation the difficult conditions which face our public school
teachers in NSW. Clearly our over-stretched teachers cannot be expected to solve the complex problems a child like Harmony faced.
Secondly, I acknowledge the particular challenges that face DCJ caseworkers and public school teachers when working with the teenage cohort. I accept the submission that there were times when Harmony made her own decisions and “voted with her feet.” She was frequently oppositional and difficult to engage. Nevertheless, the risks involved in Harmony being homeless during adolescence were in my view significant. She was exceptionally vulnerable and that was given insufficient recognition at a number of points. Ms Edwards’ reflections on two occasions when Harmony needed concrete support as a teenager were particularly insightful. Firstly at the point when Harmony was refusing to leave hospital in March 2019, and secondly when DCJ did not pursue a temporary care agreement with Rachel in October 2019. It is unacceptable to expect disadvantaged teenagers to fend for themselves, no matter how difficult they may be to engage. The risks facing a teenage girl like Harmony must be recognised.
Thirdly, I acknowledge that it is necessary to be mindful that the events under consideration took place a considerable time ago. I accept Ms Edwards’ evidence that the child protection system is currently subject to unprecedented levels of reform. She identified that issues of how triage, prioritisation and allocation occur are central to the current review. Her comment that this reform will go beyond “tinkering around the edges” and encompass a real shift was welcome but is, as yet, untested. The need for major reform in the child protection system is well established and in my view urgent.
Issue 1 Cause and manner of death
Harmony died in the early hours of 14 January 2020. I am satisfied that the cause of Harmony’s death was hanging.
The Autopsy Report of Dr Lorraine Du-Toit Prinsloo dated 21 January 2020 noted a near circumferential ligature abrasion mark was present around Harmony’s neck.
NSW Police investigated the manner of Harmony’s death. A finding that a death is intentionally self-inflicted should never been made lightly. During the investigation, NSW Police were informed that Harmony’s brother found a suicide note shortly after her death.
No such note has ever been found. Nevertheless, the deliberate actions taken by Harmony, in circumstances where I am able to find that she was alone, are strong
evidence of her intention.
Issue 2 If Harmony died by suicide, what factors led her to take that action.
Although it can be impulsive and reactive, in my experience as a coroner, an intentionally self-inflicted death is rarely caused by a single event.
Counsel assisting submitted that the evidence before the Court discloses a number of factors leading to Harmony’s decision to take her own life. She submitted that Harmony’s decision occurred in the context of isolation and disconnectedness, drawing attention specifically to her withdrawal from school, the breakdown of her placement in the community and her return to living with her mother and Nathan in a short-term motel placement. Harmony had experienced abuse, neglect and violence.
In describing the circumstances of dislocation, Counsel assisting drew my attention to DCJ’s failure to protect Harmony from the clear risk of harm that arose from her living with her mother and Nathan at the relevant time. She also noted that Harmony’s decision not to attend school was complicated by the way her suspensions were imposed, specifically noting School 3’s failure to ensure her return to education at the conclusion of the last suspension period. I accept these factors as matters which contributed to Harmony’s dislocation and isolation and accept that they form the relevant context for her death. I accept Counsel for DCJ’s submission that in making these findings I should be careful not to impute a direct causal nexus. As I have said, the decision Harmony made was likely to have been multi-factorial in a context where she lacked the support she needed.
Issue 3 Did Harmony prepare a suicide note prior to her death, if so, where is that note and what were its contents?
Counsel assisting submitted that there is insufficient evidence to confirm or reject a conclusion that a suicide note existed. I accept that submission.
It appears that a number of people reported to police that they had been told that Harmony had left a suicide note. However, no person ever reported having seen it themselves. One person reported that the note had been found by Harmony’s brother, Alex. However he denied having been at the Motel before NSW Police Officers arrived and he specifically denied ever having seen or removed a note.
Unfortunately, in my experience, the shocking nature of circumstances such as those surrounding Harmony’s death can provide fertile ground for rumour. I have seen no evidence of a note or any other final communication from Harmony.
Issue 4 As to Harmony residing with her mother Susan and Nathan Parsons, a. Was the NSW Department of Communities and Justice (formerly known as Family and Community Services (NSW) (“DCJ”) aware that Harmony was residing with Susan and Nathan contrary to orders of the FCFCOA, and if so, i. How did DCJ come to hold that knowledge; ii. Why was that arrangement permitted; iii. How was that arrangement monitored to ensure Harmony’s safety, welfare and wellbeing.
b. Is there and/or should there be a process in place where DCJ has power to make enquiries of the FCFCOA under Chapter 16A of the Care Act, or by other means, as to non-contact for children?
Counsel assisting set out the brief facts relating to DCJ’s knowledge of the FCFCOA orders.
Harmony became known to DCJ in 2005, with DCJ providing limited ad hoc engagement until 2008.
The most significant early contact was following a report of an assault by Richard on Susan on 31 July 2008. New South Wales police officers attended their home and observed it to be “filthy” and “unsafe”. A report to the DCJ Helpline followed this incident.
Concerns in relation to Alex’ school attendance, instances of morning intoxication of Susan and whether Alex and Harmony were sufficiently fed were reported.
Following this incident Richard sought psychiatric treatment as a mental health inpatient for a week before relocating to a cabin on his mother and her partner’s property. He was also charged with domestic violence and malicious damage offences.
On 4 August 2008 DCJ staff attended the family’s home and deemed it unfit to live in.
Susan and the children went to live with her father until the house was cleaned. On 5 September 2008 DCJ staff attended the family home and found it remained unfit to live in. Alex and Harmony were placed by Susan with her mother. The children remained with Susan’s mother for one week and were then placed with Richard’s mother. In November 2008 Alex and Harmony commenced living with Richard at his mother’s property as he had apparently detoxed from drug use by that time. In late 2008 Susan commenced a relationship with Nathan. On 22 January 2009 DCJ closed the 2008 case due to the risk to both children being assessed as low.
There were no reports to DCJ during this period. On 30 September 2013 the FCFCOA made orders, by consent, on a final basis. In short, the orders gave Richard sole parental responsibility for Alex and Harmony. Contact for Susan was greatly restricted and was dependent upon her providing 12 months of monthly clean supervised drug urinalysis results. Susan was specifically restrained from allowing Nathan to spend unsupervised time with the children.
These orders were never changed and remained in force at the time of Harmony’s death.
It is clear that DCJ was aware of the existence of these Court orders, at least from August 2016 when Harmony’s paternal grandfather reported the fact and effect of the orders to it. He contacted DCJ on 3 August 2016, following Harmony not returning to the Central Coast after a visit to her maternal grandmother in the July 2016 school holidays. He reported that Harmony was living with Susan and Nathan in clear breach of the orders which had been designed for the children’s safety. The notation made at the DCJ helpline states the information was considered “somewhat vague and there may not be enough information to warrant FACS intervention.” The report was screened as non-ROSH.
A similar report was made on 12 August 2016. Once again the breach of conditions regarding contact between Susan and Harmony were stated. That Helpline record reports that Harmony and her brother had been presenting to school every day clean and fed and that there were no issues of concern. The report was again screened as non-ROSH.
It is important to note that from its first review of this matter during the ICDR, DCJ
conceded this report was incorrectly screened.
On 16 August 2016 another report was made to DCJ. The caller referred to the FCFCOA and expressed concern about Harmony.
A DCJ file note of 17 August 2016 records that the Court order would be obtained via a school through the Taree Service Outlet. The orders were received by email on 18 August 2016 and a copy of the Court order is found in the DCJ file immediately following the letter dated 17 August 2016 and preceding the email of 18 August 2016.
On 16 August 2016 DCJ rescreened both Alex and Harmony for significant neglect and referred the case to the weekly allocation meeting (WAM). That meeting occurred on 22 August 2016 and during the meeting it was documented that the FCFCOA orders prohibited Nathan having contact with Harmony or her brother. It was noted that further investigation was required and the case was held over to the next WAM. The case was back before the WAM on 7 September 2016, where it was considered for allocation.
However, on 14 September 2016 the case was closed as DCJ was “unable to respond” to this report “due to competing priorities”.
Notwithstanding the fact that educators also raised the issue with DCJ on a number of later occasions, including in May 2018. It is difficult to understand DCJ’s approach to the orders.
This is certainly correct. Susan’s drug use and her ongoing relationship with Nathan were live issues for Harmony’s safety at that time. Counsel assisting submitted that closing this ROSH report in those circumstances and taking no action represents a significant failing by DCJ. Counsel assisting submitted that once DCJ was aware of the orders, their breach and the continuing risk that breach represented, a copy of the orders should have been immediately requested.
Counsel for DCJ accepts that there was in effect a two week delay in obtaining a copy of the formal orders. Further, DCJ accept that while there was a clear failing in the decisionmaking process which had earlier assessed the risk as non-ROSH, it does not identify the two week delay in obtaining the orders as a critical factor in the flawed decision making process. It is a matter I will return to when considering recommendations.
It is clear that Chapter 16A of the Care Act is already sufficient to allow DCJ to request information, including Court Orders from the FCFCOA. I will return to the issue of whether all DCJ staff are sufficiently aware of this power when I consider recommendations.
While I acknowledge the delay in requesting and receiving the Court Orders, it appears to me the DCJ’s real failure is much more significant. Not only was there an occasion where a report was incorrectly screened at the Helpline, once a report had been correctly screened and quite properly made its way to the WAM, it was closed “due to competing priorities”.
I have no trouble accepting that there were competing priorities facing caseworkers tasked to allocate work at the WAM. Prioritisation decisions such as these must be almost impossible to make and undoubtedly contribute to the extreme pressure on all staff involved. What I do not accept is a departmental ethos where these kinds of decisions are seen as “business as usual”. As I have said on many occasions, DCJ is the agency in NSW tasked with a statutory responsibility for protecting children and young people from risk of significant harm. That is a responsibility that cannot be shifted by creating a culture where overworked staff can close reports, claiming a lack of resources or “competing priorities.” DCJ must be made to grapple openly with these issues at the highest level and to find solutions to the ongoing resourcing issues identified. Where risk of significant harm has been identified, DCJ has a responsibility to act.
I was informed that triage, prioritisation and allocation are major issues in the reform work currently being undertaken by DCJ. Without knowing more, I can only hope very significant change is imminent.
Issue 5 As to ensuring the safety, welfare and wellbeing of Harmony, in the period between January 2015 and 14 January 2020: a. Was the review and response of DCJ to the reports made about Harmony appropriate; b. Were the interactions between Harmony, Susan, Nathan and other members of Harmony’s extended family adequately monitored and responded to; c. Were appropriate steps taken to ascertain whether there was any person available to provide out-of-home care for Harmony.
The reports which are detailed in the chronology disclose parental neglect, violence at
home and instances of running away, among other issues.
The report identifies six reports between 2016 and 2019 which were incorrectly screened.
While recognising this failure, DCJ state that more recent guidance issued to staff make it “more likely” that reports would be accurately screened today.
I do not intend to discuss each of the reports set out in the attached chronology or reviewed in the ICDR report, however it is useful to examine some examples which are illustrative of the inadequacy of DCJ’s response to the cumulative harm Harmony suffered.
When Harmony self-placed with her paternal grandmother and her husband, DCJ decided it need have no further role. By October 2017 the family made it clear they needed support and referrals. This was hardly surprising given Harmony’s trauma background. However, before any real progress was made the placement broke down.
With hindsight it is perfectly clear that the chances of such a placement surviving without support were extremely low.
On 26 October 2017, Harmony was placed at Woy Woy Children and Young Person’s refuge. She was only 13 years and five months and in year seven at school. DCJ closed her case as Harmony was now judged to be “safe and supported”. I do not accept this as accurate or appropriate.
Counsel assisting submitted that it is unclear what steps DCJ took in the period 26 October 2017 to 25 November 2017 to find Harmony accommodation outside of a refuge and with a person who had the capacity to care for her on a permanent basis. The only documented enquiry made by DCJ as to the availability of family members is a telephone call with Harmony’s paternal aunt on 26 October 2017. It does not appear that contact was made by DCJ directly with Harmony’s paternal grandfather or any other family members. Harmony’s paternal grandfather stated that DCJ had no contact with him regarding Harmony following his report in August 2016 until 29 August 2018.
No application was made under the Care Act to ensure that there was someone exercising parental responsibility for Harmony. There is no evidence that DCJ engaged in a process of finding permanent long-term accommodation. This is despite DCJ being well aware that there was no parent exercising parental responsibility or able to exercise parental responsibility without the variation of a Court Order.
Records show that this was an unsettled period for Harmony. New South Wales police officers attended the refuge to speak with Harmony about reports from a parent of her bullying their child at school, and Harmony was suspended on two occasions, between 2-6 November and 23-24 November. On 25 November 2017, four weeks into her placement at the refuge, Harmony left through a bedroom window after 11 PM. The refuge made a Helpline report and speculated that Harmony may have been returning to live with Susan and Nathan “who there are orders against due to safety concerns”.
On 28 December 2017 DCJ records state “it is possible that [Harmony] has gone to stay with her mother and her partner who there are orders against due to safety concerns.
While concerning, the whereabouts of [Harmony] is currently unknown so it is unclear whether these living conditions represent a risk of significant harm for [Harmony]. Since it is not known whether she is currently in the care of her mother and partner there are no safety concerns known.” There was a very disturbing lack of curiosity in relation to what was really going on for Harmony at this time. The response was wholly inadequate.
The decision to close her case at this point in circumstances where she had not been located, was 13 ½ years of age, and possibly living with persons who were known to cause her harm is in my view seriously flawed. I accept Counsel assisting’s submission that to suggest there were no safety concerns shows a lack of insight, is unreasonable and represents an unjustifiable assessment of Harmony circumstances.
Harmony returned to live with her mother and re-enrolled in School 3 on 1 February 2018.
On or about 26 July 2018, Harmony was found sleeping rough in a park by a school friend and her mother and was taken to their home. Harmony lived with them until 14 August
Harmony was observed to have extensive bruising to her face and body. She later disclosed that the bruising was caused by an assault from Nathan. Records show that Harmony reported to NSW Police an assault on her mother by Nathan around this time.
On 27 July 2018 and 29 July 2018, mandatory reports were made to DCJ by School 3 reporting Harmony’s homelessness. It appears DCJ conducted an Alternate Assessment (SARA Exception) at this time and subsequently organised for Harmony to return to her paternal grandfather’s care “on at least a trial basis”.
On 7 September 2018, DCJ proceeded to close Harmony’s case determining that the placement with her paternal grandfather was not a DCJ placement and it no longer required DCJ involvement.
Counsel assisting submitted that although the Alternate Assessment (SARA Exception) was an appropriate case management tool to apply, as was the decision to contact the paternal grandfather, the decision to classify the placement as not a DCJ Placement, and to not take steps available under the Care Act, was not appropriate. I accept that view.
Counsel assisting contended that had DCJ invoked the Care Act, supports could have been arranged and instigated by DCJ and the placement could have had some form of ongoing case management. Counsel assisting concluded that in the circumstances, it was not enough to simply inform the family of the possibility of seeking support.
Further, Counsel assisting submitted that DCJ’s response continued to be inadequate throughout 2019. It appears the placement with her grandfather broke down and Harmony returned to the care of her father on around 1 January 2019. DCJ were not aware of this change. Harmony commenced year 9 at School 4 and received her first suspension the following month.
On 27 February 2019 Harmony was taken to hospital having taken her father’s medication.
When she was medically cleared for release in early March 2019, Harmony refused to return to her father’s home. This was an opportunity for intervention. Counsel assisting submitted as follows: a. There was a failure to engage with the safety and stability concerns that Harmony was clearly articulating to hospital staff which were being relayed to DCJ in clear terms.
b. There was a lack of understanding of the impact of cumulative harm to Harmony and how that played into assessing her risk and appropriate responses to reports made to DCJ.
c. There was a lack of engagement with Harmony upon her discharge from hospital to understand her views as to accommodation, including whether refuge accommodation was appropriate and necessary (noting the availability of Rachel to care long term for Harmony).
d. There was a lack of engagement with Richard who held parental responsibility for Harmony as to what supports could be provided and what short term accommodation arrangements could be made during a period the parental/child
relationship could be addressed and potentially remediated.
e. DCJ’s lack of engagement with Rachel was a missed opportunity to provide to Harmony, a long term, supportive and loving family environment.
f. There was a total disregard of the SAFE assessment conducted in August 2018 that expressly stated it was not safe for Harmony to reside with her mother and Nathan.
g. DCJ ought to have engaged with the Care Act and taken steps available to it to ensure the safety, welfare and wellbeing of Harmony was appropriately addressed.
h. There was a failure to find other suitable accommodation for Harmony following being placed at Woy Woy Refuge.
I accept Counsel assisting’s summary of the identified failings of DCJ. I note that many of these issues were not disputed by DCJ and had been identified in their own internal report.
Between May and August 2019, Harmony’s difficulties continued. School 3 made further reports to the Helpline on 24 May 2019 and 2 July 2019. Little was done. In August 2019 Harmony’s case was transferred to the Central Coast Multi-Agency Response Centre (CCMARC). CCMARC ultimately made a referral to Evolution Youth Service and caseworkers informed Rachel to contact the Helpline if she could no longer care for Harmony. CCMARC closed the case as it had “no capacity to allocate”. Counsel for DCJ submitted it should be remembered when analysing this referral that our current child protection system relies on partnering with appropriate Non-Government Organisations to provide child protection services. This is undoubtedly true. Nevertheless, there comes a time when a statutory response and intensive case management is required, and in my view the threshold for this had been well and truly been crossed.
The overall response was inadequate. It appears to me that there were numerous points between 2015 and 2020 where DCJ should have taken action and this was one of them.
This was accepted by Ms Edwards who stated “we should have stepped in at that point in time and we didn’t”.
Nathan. Harmony’s situation was increasingly hopeless and analysis of her online contact reflects her growing despair.
Issue 6 As to the movements of Harmony between 6 and 8 March 2019: a. What legal framework supported the placement of Harmony with Rachel Corsi on or about 6 March 2019; b. Why was Harmony placed in a refuge on or about 8 March 2019; c. What consultation with Harmony and Rachel occurred prior to the placement of Harmony in a refuge on 8 March 2019.
Harmony was transported to Gosford Hospital from school on 27 February 2019. She had taken an overdose of her father’s anti-depressant medication. On 5 March 2019 she advised DCJ that she refused to be discharged into her father’s care. The following day she advised DCJ that Rachel had offered her a place to stay.
Rachel was the kind and generous mother of one of Harmony’s friends and she was keen to help when Harmony was discharged from Hospital. DCJ were informed that Harmony would be living with Rachel.
No legal framework supported this placement, it was an informal arrangement which DCJ were aware of, but which fell outside the Care Act. There were no DCJ supports put in place to assist Rachel at this time.
The ICDR Report recognises that a Temporary Care Arrangement (TCA) could have been made with Richard’s consent. This could have allowed Rachel to become an authorised carer. Of course it is unknown what Richard’s position might have been as the process was never explored.
On 8 March 2019, Harmony had an issue at school and DCJ were contacted. DCJ advised that they would not collect Harmony from school as they did not hold parental responsibility. The school contacted Woy Woy Youth Refuge and arranged for Harmony to be collected. This placement became permanent and there appears to have been no attempt to engage with Rachel or to consider other options at this time.
I am critical of DCJ’s failure to take more responsibility at this time, particularly when Harmony placed in a Youth Refuge. I accept that many of these lost opportunities were identified in the ICDR Report or in the evidence of Ms Edwards. I accept the finding of the ICDR Report which identified that a focus on the accommodation issue meant that the team lost sight of the broader risks facing Harmony.
Issue 7 Was NSW Police Force aware that Harmony was residing with Susan and Nathan contrary to orders of the FCFCOA, and if so, a. How did NSW Police come to hold that knowledge; b. What steps, if any, did that take in response to that information; c. Why did NSW Police facilitate the return of Harmony to Susan and Nathan’s care on or about 25 October 2019.
Issue 8 Did the NSWPF adequately respond to and investigate reports made to them by Harmony and others that Harmony was at risk whilst living with her biological mother and Nathan?
The Court had the detailed evidence of Chief Inspector Mark Dixon of the Child Wellbeing Unit, Police Link Command, as well as evidence contained in records of the COPS system. Chief Inspector Dixon set out there were a total of 13 COPS events in relation to Harmony and that on each occasion the attending officers responded appropriately to the reports made.
Counsel assisting submitted that the available evidence demonstrated that police who had involvement with Harmony and her family were alive to the risks and made appropriate assessments and reports to the Child Wellbeing Unit.
In particular, the inquest considered the actions of NSWPF following a report made by Harmony on 25 July 2018, alleging that Nathan was hurting Susan.
NSWPF attended the home in response but their interaction with Susan and Nathan did not suggest injury to Susan. Harmony was not sighted at the scene and despite efforts to follow up with her, she declined to engage further with NSWPF. In response to the incident, the NSWPF appropriately completed a Child at Risk Incident report and applied the Domestic Violence Mandatory Reporter Guide with a no ROSH outcome. The report was forwarded to the NSWPF Child Wellbeing Unit for further assessment.
Counsel assisting submitted that NSWPF responded appropriately to this incident. The Commissioner of Police made no further submissions on this issue.
Issue 9 Could processes between NSWPF and DCJ be improved to assist police in identifying and reporting on children and young people at risk of serious harm and / or neglect?
Chief Inspector Dixon described the processes police use for identifying children at risk including through the Domestic Violence Safety Assessment Tool which is applied at domestic violence incidents, as well as the options available to NSW Police with the Child Protection Helpline.
Further, Chief Inspector Dixon explained the mechanisms available to NSWPF where an officer believes there is an immediate risk of significant harm to a child, including the power of removal under s 43 of the Care Act and the ability to request an emergency/afterhours emergency response from the Child Protection Helpline. Alternatively, a NSWPF officer is able to call the Child Protection Helpline to outline their concerns where they believe an urgent response is required.
Issue 10 In the period between January 2015 and 14 January 2020, did the DoE sufficiently respond to allegations of neglect, abuse and violence against Harmony?
This issue assumed some significance during the inquest. The Court accepted the evidence of Professor Linda Graham, specifically her research which identifies the potential of school connectedness to be a strong protective factor particularly for children and young people who experience chaotic or violent home lives.
Professor Graham looked specifically at school exclusion for students who have experienced abuse or trauma at home or who may be living in care. She stated “school may be the only source of social connection, validation and care for vulnerable young people.”
I accept Counsel assisting’s submission that there is clear evidence that School 2 and School 3 were aware of allegations of neglect, abuse and violence against Harmony in the home. Both schools reported allegations to DCJ in accordance with their obligations.
I also accept that DoE is generally aware of the importance of school connectedness for young people and has policies which reflect that understanding. Nevertheless, whether
Harmony’s unauthorised absences from School 3 were adequately managed was a matter explored in the evidence. Counsel assisting submitted that while DoE identifies not attending school regularly as a child protection concern, it was not apparent that Harmony’s absences were always managed in accordance with this policy.
Counsel assisting took me to particular examples. For instance, a report made on 7 August 2017 referred properly to domestic violence, homelessness and risk-taking activities, but did not reference the very significant school absences during the same period. In Counsel assisting’s submission these absences, while connected to violence, abuse and neglect in her home life also constituted a separate issue of educational neglect which should have been identified to create a more complete picture.
Counsel for DoE submitted that in circumstances where DCJ were apparently involved and aware of the critical issues, there was limited need to report educational neglect as a separate issue. I accept that the school expected Harmony’s attendance rate would rise once her domestic situation improved. I also accept that the school had a right to expect DCJ were actively involved. Unfortunately this understanding was misplaced in the circumstances.
Counsel assisting also drew my attention to other examples. For instance, School 4 did not separately report the very significant absences in March and April 2019 while Harmony was living in a youth refuge.
Nevertheless, I accept the submissions of DoE that there are also specific reports of educational neglect. School 3 made a report of educational neglect on 24 June 2019, stating that Harmony’s attendance was at 30%. At the same time, it was reported that there was no electricity or running water at home and the presence of domestic violence.
Further, the DoE submitted that on 4 July 2019 and 22 August 2019, further reports of educational neglect were made by DoE staff to DCJ, reporting Harmony’s lack of school attendance and alleged drug use. While I accept that there were certainly times when educational neglect was not given specific emphasis, when the records are examined as a whole, it is clear that Harmony’s teachers understood her lack of school attendance as part of an overall picture that was very worrying. I am also mindful of the evidence given by the school principals who were involved in these proceedings. They gave evidence of the significant number of young people who faced issues not dissimilar to Harmony and the pressure that places on a school with regard to personalised liaison with DCJ in each case.
Issue 11 Could the NSW Department of Education’s response to Harmony’s truancy have been better managed?
A review of Harmony’s school attendance records discloses many absences without explanation. These occur more frequently after periods of suspension and during periods where her home life was in crisis.
Professor Graham described the negative impact of unexplained absences as “well documented.” I accept that those impacts go well beyond creating gaps in a child’s academic progress and can have long lasting social impacts for a child who loses school and peer support and who may no longer be visible to professionals who could assist.
Counsel assisting submitted that a review of the evidence discloses a likely connection between suspension from school and further unauthorised absences. My attention was drawn to Harmony’s attendance in 2017 when she was living with her mother. On 27 March 2017 Harmony was suspended for 20 school days. The start date was the second last week of school term. For this reason, the suspension continued into the first and second weeks of the following term, not ending until 5 May 2017. Harmony then failed to return to school for a further eight school days. Counsel assisting calculated Harmony was thus away from a school environment for 7.5 weeks, a very significant period of disengagement. This lengthy period was especially concerning when there was no evidence that School 3 took specific steps to engage with Harmony and her family during this period to provide assistance with a home learning program. While school work may have been provided by some teachers, it was unrealistic in the circumstances to think that without significant support Harmony would be able to engage meaningfully in academic tasks at home.
Counsel assisting submitted that there should have been consideration of the impact of the school holiday period and the way in which this contributed to Harmony’s disengagement. It was submitted that the start of the new term could have served as a reset for Harmony.
Teacher 1, Principal of School 3 was taken to the issue. He accepted the new term could be seen as a reset. However, he was not aware of any specific policy or guideline for principals considering imposing a long suspension to take into account the impact of school holidays and the effect holidays may have on lengthening the period of disengagement.
I accept Counsel assisting’s submission that with hindsight the impact of this suspension is clear. Harmony returned to school in May 2017, apparently having not completed any tasks at home. She was behind in her studies and it contributed to her disruptive behaviour in class. The attendance records for the following months show only sporadic attendance. In June for example, Harmony went to school for six out of a possible 20 days.
While she received short suspensions during the period she lived with her paternal grandfather in 2017, there were also good behaviour reports, engagement in work experience and weekend work. Overall she had a pattern of better attendance when she was living in a more settled environment.
By the time she was living with her father and then in the refuge in 2019, Harmony was subject to a number of suspensions and her attendance was poor. This continued when she returned to her mother’s care. Perhaps not surprisingly, a close examination of the records clearly demonstrates that when she was feeling unsafe or when there was violence or dysfunction in her life, her engagement with school declined both through suspension and through non-attendance.
Teacher 1 told the Court that Harmony’s behaviour “was such that she could have been suspended far more frequently than she was” and that in fact efforts were made to “keep her in school as much as possible”. He spoke of the need to balance the safety and security of other students and teachers at the school with Harmony’s education and wellbeing. I accept it must be a difficult balance to strike. I also accept that many students at School 3 also came from traumatic backgrounds and Harmony’s behaviour may have been potentially triggering to others at times. Teacher 1
also gave evidence of the school-based strategies that were attempted with Harmony.
Counsel for DoE set out the reasons for each of the five suspensions from School 3 between 2017 and 2019, arguing that in each circumstance a suspension was appropriate.
Harmony was suspended seven times from School 4 between 2017 and 2019. The Principal of School 4, Teacher 6 advised that suspensions were used as a last resort and if a child came from an unstable home environment he personally spoke to the parents or made reports to the Child Protection Helpline.
I accept that the factors driving Harmony’s truancy and suspensions could not be
addressed by DoE alone. I also accept that a school needs to take into account the rights of other students to learn in a peaceful environment and the rights of teachers to a safe workplace.
It is unfortunate that the alternatives to suspension, including in-school suspension and the external PCYC suspension centre were not suitable options for Harmony. The Court heard evidence that an in-school suspension required the student to sit in front of the Principal’s office and work for the day, which was not an appropriate option for Harmony, who would have been unlikely to engage in such circumstances. Further, the available suspension centre was not safe for vulnerable students, particularly female students due to such suspension centres being largely catered to male students. The evidence provided to the Court suggested that although there are services for female students in school, there are limited options available for female students outside of the school environment.
I accept that DoE could not solve Harmony’s many problems and needed to balance the rights of other students. Nevertheless at the conclusion of evidence I remained very troubled by how often she was suspended. I was informed that there was no suitable suspension centre for her to attend, but clearly what she needed, if she could not remain at school, was trauma informed, small group support. These resources do not exist and individual principals were left to use a disciplinary system which was not fit for purpose when it came to Harmony.
Issue 12 Was the decision of the Department of Education to not prioritise Harmony’s access to the formal Home School Liaison program appropriate in the circumstances?
gave evidence that a referral to the Home School Liaison Program (HSLP) could have been made, but he did not accept that it should have been made in circumstances where the HSLP was under-resourced and where Harmony was receiving help from other sources.
School 3 is situated) were allocated to the HSLP caseload.
The real limitations on the resources available to the HSLP appear to mean that a very high threshold must be crossed before a referral is made. While HSLP Officers (HSLO) may be engaged with teachers about strategies at a general level, the opportunity to work closely with individual students and their families is apparently rare.
Harmony was allocated a HSLO in July 2019 and clear efforts were made to engage her and Susan, without success. By the time contact was made with Susan on or about 29 October 2019, the HSLO was informed that Harmony had left the area to live in the Central Coast and Susan did not know where she was. Further contact details were sought through the Child Wellbeing Unit, but Harmony’s grandfather had no new information. There were further attempts but the file was closed on 2 December 2019. It was decided that Harmony could not be located and was not enrolled. It was submitted that had Harmony remained unenrolled at the commencement of term one in 2020 there would have been an opportunity for additional follow up. However, by the commencement of term one, Harmony was dead.
It became clear as the inquest progressed that major reform is needed to recast and better resource the HSLP. The Court was provided with a copy of the Home School Liaison Program Draft Evaluation Report and became aware that while all stakeholder groups participating in the review saw the HSLP as necessary and valuable, there was also a broad consensus that it is not operating optimally. A very extensive list of recommendations was generated, some of which were described as “aspirational” by Mr Graham, due to likely funding constraints.
The Court was advised the report was due to be finalised by August 2024 but had been delayed by staffing issues. Mr Graham advised that it would be finalised “hopefully this year.” The Court is unaware if any progress has been made in this regard.
Issue 13 Do the NSW Department of Education’s behaviour management policies appropriately consider the impact of suspension on children with a known history of family domestic violence?
significant long term risks.”5 I am not surprised to learn that students from disadvantaged backgrounds, students with disability, indigenous students and children in care are disproportionately overrepresented in school suspension statistics.
It is recognised that a decision to suspend a child is often a difficult one that needs to weigh competing interests. Nevertheless, Counsel assisting submitted that there is no policy which requires that explicit consideration be given to the safety of the home a student would be suspended to, whether the home environment poses future risks or how a child might be adequately supported during a suspension.
Counsel for DoE submitted that current policy already requires consideration of a student’s vulnerability. Currently, the principal must consider “the student’s educational and safety needs” and individual circumstances including but not limited to their trauma background, interactions of out-of-home care and socioeconomic disadvantage. The principal must also consider “the student’s wellbeing, risk and potential vulnerability before implementing a suspension.” The parents and other support persons (within and outside the school) must be involved early; a suspension cannot begin until all reasonable steps have been undertaken to notify parents or caregivers of the expectation that the student will continue a learning program provided by the school, whilst they are suspended.
Further, Counsel for DoE submitted that the Department is willing to provide additional support to schools, so they are able to better identify vulnerable students.
I accept these policies are in place but without the availability of proper alternatives such as the provision of trauma informed external exclusion centres and better resourcing of school counsellor positions and wellbeing staff, overstretched public schools will continue to suspend students knowing they will be unsupported and even potentially unsafe at home. More must be done to ensure that students who are at risk of family violence in the home are identified before a school decides to suspend.
The need for Recommendations
5 Report of Professor Graham, Tab 71, page 9
Prior to that it is worth describing some of the changes to procedures and processes made by both DCJ and DoE since 2020 as these changes impact significantly on the need for recommendations.
As I have already stated, Ms Edwards described the current environment as one of significant change for DCJ, the potential impact of which is not yet clear. She also outlined a number of concrete changes which have been made and which were neatly summarised by Counsel for DCJ, as follows: a. Implementation of the revised Triage Assessment Mandate across all CSCs since February 2022. The aim of the revised TAM was to ensure that children at highest risk are prioritised for a face-to-face response. Additionally, DCJ is currently undertaking a comprehensive review of its prioritisation, triage and allocation processes (incorporating extensive stakeholder consultation); b. Since December 2021, introduction of improved guidance to caseworkers on selfharm and suicide (including supporting practitioners to identify risk factors and warning signs) – namely, the ‘Guidelines for Risk Assessment and Management of Suicide and Self-Harm’; c. Revisions to the ‘Mental Health Practice Kit’ in May 2022, which includes an additional chapter focussed on suicide and self-harm; in January 2023, practice advice was also reviewed and improved; d. Since April 2021, conducting training in the form of ‘Evan’s Story’, being a poignant case study to enhance practitioner awareness of young people and early warning signs about suicide; e. From July 2024, providing updated (3 hour) workshops for practitioners in ‘Assessing and responding to suicide and self-harm’, built around ‘April’s story’, which provides a realistic case study to learn from, and includes participants practising gathering information and developing a safety plan for young people (amongst other casework steps); and f. Ongoing group supervision sessions by the leadership group within CCMARC which aims to support district leaders develop their skills as effective practice leaders, amongst other matters.
The Court also received evidence about changes the DoE has made in relation to relevant issues. In particular the Court was informed about changes made to suspension policies since the time of Harmony’s death, which include the following: a. In 2022, the removal of short and long suspensions and inclusion of a single suspension duration of between 1 and 10 school days for students in Years 2 to 12 and the removal of short and long suspensions and the inclusion of a single suspension duration of between 1 and 5 days for students in Kindergarten to Year 2.
b. In 2024, the policy was updated although it made no changes to the shorter suspension durations that had been introduced by the 2022 policy. The 2024 policy introduced a non-exhaustive list of specific behaviours of concerns as grounds for suspension, rather than two broad grounds of suspensions contained in the 2022 policy (actual harm and unacceptable risk of harm) or the long and short suspension categorisation in the policy in place at the time of Harmony’s death.6
Mr Graham gave evidence about the Team Around a School (TAaS) model which was introduced in 2022 and which includes school-based specialist staff, including HSLO and non-school based Student Wellbeing Support directorate staff. He suggested this program can strengthen partnerships and connect the school to staff with specialist skills. It should strengthen support for students with complex needs like Harmony.
DoE also advised the Court of a recent relevant review which was undertaken into the operation and effectiveness of the HSLP. A copy of the draft Home School Liaison Program Draft Evaluation report was provided to the inquest.
These changes and reviews are relevant when considering the need for recommendations, which must arise from the evidence and be necessary and desirable.
Draft recommendations put forward by Counsel assisting
Where DCJ staff become aware of a potential breach of a pre-existing Court order, that DCJ Helpline Protocols be updated and clarified to require a copy of the relevant orders be obtained from the FCFCCA or NSW Police as relevant.
Accepting that in this case the relevant orders were not received until approximately two weeks after the Helpline had been advised of their existence and the fact that they were being breached, Counsel assisting requested consideration of a recommendation which would mandate obtaining the orders at an early point.
DCJ did not support the recommendation and Counsel for DCJ set out a number of concerns which included that the recommendation might create additional and time consuming work for Helpline caseworkers who are already under resourcing constraints.
Further, it was suggested that a mandate may even delay a report moving through the system. Counsel for DCJ drew the Court’s attention to Ms Edwards’ statement which made it clear that while Helpline staff can request a copy of FCFCOA orders there is no “mandate” for them to do so.
While submitting that the recommendation was neither necessary nor desirable, Counsel for DCJ also drew the Court’s attention to the fact that work is currently being done to ensure that FCFCOA information is placed on the DCJ system in the quickest and most efficient way possible. A letter provided to this Court under the hand of Elaine Thomson, Acting Executive Director, Office of the Senior Practitioner makes it clear that the Director of the Helpline is aware of these discussions.
Ms Thomson also made clear that DCJ has initiated changes in the guidance available to Helpline practitioners to include a prompt to consider any existing Court orders and any subsequent impact on a child’s safety. This can occur while ensuring that reports are transferred to the relevant CSC as soon as possible without waiting for the material to be provided.
I am satisfied that in these circumstances it is unnecessary to make the recommendation suggested.
Draft Recommendations Two and Three That guidelines be created for the provision of practical support to community or family members who do not hold parental responsibility.
That practical information such as counselling resources, assistance with schooling including literacy and numeracy programs parenting support, financial support, case work support and information on bringing a Care Application where the placement is assessed as being potentially long term, be provided to carers who do not hold parental responsibility. This information is to be made available online and made available in hard copy through local CSCs.
Counsel assisting drafted two recommendations aimed at enhancing the support given to any person who is providing care to a child, for whom they do not hold parental responsibility, so that ongoing risk to that child is decreased and the chance of a stable arrangement is increased. The recommendations arose directly from the evidence in Harmony’s case, specifically on Ms Corsi’s experience with DCJ. I intend to deal with the draft recommendations together.
Ms Corsi felt unsupported and while there is evidence that there was an attempt to refer her to Evolution Youth Service, I accept the support offered to her was inadequate.
DCJ accepted the rationale for the recommendations and the Court was informed that the Serious Case Review (SCR) team consulted with the Systems Reform team in an attempt to determine how best to meet the intent of the recommendations, keeping in mind changes that have been made since Harmony’s death in 2020.
The Court was taken to the Unaccompanied Children 12-15 years Accessing Specialist Homelessness Services Policy which now requires cases concerning a child who is homeless and assessed as ROSH to be allocated. The policy also sets out roles and responsibilities for DCJ and youth homelessness services. Commencing in July 2021, this policy has clear relevance to the circumstances which faced Harmony. The Court was also referred to various online resources which have been created to provide information about support services, resources and information as well as the Responding to a person who contacts the CSC mandate.
DCJ proposed the following revised formulation combining the two recommendations.
DCJ should undertake the following, to ensure practitioners are aware of the support available to community members who take on care of the child for whom they do not have parental responsibility:
a. As part of DCJ’s current review into triage processes DCJ provide written guidance to triage practitioners about the provision of support to community members or family members who do not hold parental responsibility but are providing care and housing to a child, including practical information such as counselling resources and parenting support; and b. Communications are issued to triage practitioners with a link to the Responding to a person who contacts a CSC mandate and explaining DCJ’s direction to provide supports referrals and information regardless of whether the person is a parent, or a family or community member who is caring for a child to whom they do not hold parental responsibility.
Draft Recommendation 4 That Harmony’s case be developed into a case study for DCJ staff on the impact and effects of cumulative harm on children and young people exposed to trauma.
While stressing that the lessons in Harmony’s case were well accepted and recognised, DCJ submitted that the recommendation was neither desirable or necessary.
It was submitted that action taken by DCJ ensured that Harmony’s story has already been shared with practitioners. Ms Thomson confirmed that the Hunter Central Coast leadership team were to participate in a group supervision session on 29 January 2025 to consider the learning from Harmony’s case. The session was apparently used to design and inform a learning package that focusses on young people who experience cumulative harm, are at risk of suicide and who are disconnected from school and support services. The Court was informed that the district leadership team will create a plan to develop a learning package that will be delivered to all teams in group supervision over the course of 2025. I was informed that the initiative is being driven by Belinda Edwards, the Executive Director of the Hunter and Central Coast District. I had the opportunity to hear from Ms Edwards and she impressed me as a thoughtful leader with an appetite for change.
For this reason I have decided not to make a formal recommendation in this regard, satisfied that the lessons from examining the circumstances Harmony’s death will be shared.
Recommendation Five Consideration be given to whether the Unaccompanied Children and Young People 12 – 15 Years Accessing Specialist Homelessness Services Policy (23 July 2021) is being appropriately applied to the effect applications under the Children and Young Persons (Care and Protection) Act 1998 are being made.
I carefully considered making this recommendation and question whether the Policy has driven better outcomes for young people between 12 and 15 accessing homelessness services, as expected.
However, I accept Counsel for DCJ’s submission that a single inquest from a death in 2020 may not be a solid basis to trigger the complex review which would be required to answer the question raised by Counsel assisting in 2025. While I share Counsel assisting’s concerns and consider the issue an important one, I have decided against making a formal recommendation. Most persuasively, I note the NSW Ombudsman’s report “More than shelter – outstanding actions to improve the response to children presenting alone to homelessness services” and the DCJ response, which is publicly available.
To the Department of Education (‘DoE’): Recommendation Six Recognising that the Home School Liaison Program (‘the Program’) is presently subject to review, that the Program be redesigned and redeveloped taking into account the findings of that review, and that the Program’s redesign be attended to as a matter of urgency by the DoE.
7 Home School Liaison Program Draft Evaluation Report, Exhibit 6
Many of the recommendations in the Draft Report go directly to issues squarely raised in this inquest, including the need for more robust early intervention when school disengagement is identified and the need to provide increased support for older students.
The evidence arising from this inquest certainly supports a need to better resource and target the HSLP. The program could have offered Harmony and her family more support at an early stage. Through closer contact with students the program has the potential to provide schools with more insight into the home life of a student like Harmony and with that increased visibility, there is the possibility of finding the right kind of support. However, at present it is significantly under-resourced. Mr Graham advised that only 12% of students referred to HSLP currently receive support because of the limited resources that can be allocated.
I am anxious that the report is acted upon, and not left in a drawer because action will require financial support. I intend to make a recommendation supporting a redesign as a matter of urgency and will ask the DoE to take the findings of this inquest into account.
Taking into account the submissions of the DoE on this recommendation, I make the following slightly amended recommendation: That DoE consider prioritising the redesign of the HSLP as a matter of urgency, taking into account the Home School Liaison Program Draft Report and the findings of this inquest.
Recommendation Seven That the DoE review its current suspension policy as to whether it adequately addresses the needs of children and young people experiencing abuse, neglect and homelessness, including the need for suspensions to be carried out in places external to the home environment when that environment presents a risk.
Counsel for the DoE submitted that this recommendation is unnecessary on the basis that the DoE suspension policies currently in place already require consideration of trauma, child protection and individual student needs. Further, Counsel for the DoE appeared to submit that consideration of suspensions to places external to the home environment are futile where a student returns to that same home environment at the end of each school day in any case.
Ultimately, Counsel for the DoE submitted that although further guidance can be provided to schools on how to keep vulnerable students engaged, including through the use of
shorter suspensions and alternatives to suspensions, this should be considered once the current policy has been in place for a longer period of time to allow for its effectiveness to be appropriately assessed.
Where the home is characterised by violence, abuse or neglect school may be the only source of social connection and visibility.
Principals are tasked with creating a safe space for all staff and students and I acknowledge that this will mean that particular students may at times need to be removed from the school environment. Nevertheless, the effect of that removal on a vulnerable child must be carefully considered and options for suspensions to be undertaken in safe environments away from home must be explored.
Recommendation Eight That the DoE amend its current suspension policy so that where a long suspension is imposed in the week immediately before an end of term holiday commences: a. The starting positions for that suspension be the weekdays of that holiday period to be counted towards the period of suspension; b. Consideration be given to the appropriateness of the suspension being resolved on the first day of the next term.
Counsel for the DoE submitted that long suspensions are no longer in use, with 10-day suspensions the maximum under the current policy. In my view this change is likely to be at least a step in the right direction.
With respect to (a), Counsel for the DoE submitted that counting the weekdays of a holiday period would not allow the requisite time for teachers and staff to put supports in place for the suspended child, due to schools being closed during this period and staff being on leave. Further, Counsel for the DoE argued that a blanket rule would be inappropriate from a risk-management perspective, due to the need to stagger return dates if more than one student is suspended following an altercation.
In response to (b), Counsel for the DoE submitted that this issue may be mitigated by shorter suspension periods.
I have considered the submissions of DoE carefully, but nevertheless intend to recommend the DoE give some thought to mandating a consideration of the impact of school holidays when setting a suspension period. In particular, consideration should be given to using the new term as a time to reset wherever possible. I make the following amended recommendation: That DoE give consideration to amending the suspension policy to mandate consideration of the impact of school holidays when setting a suspension period.
Particular consideration should be given to using the commencement of a new term as a reset wherever possible.
Recommendation Nine Where a student subject to a suspension is not in the care of the person who holds parental responsibility and is subject to an out of school suspension, procedures be developed to address, inter alia: a. To whom the school is to issue mandatory correspondence b. Whether the expectation of engagement by the parent or carer who the student would otherwise have resided with continues, and if not, who is responsible for engaging with the student during the period of the suspension.
In response to Recommendation 9, Counsel for the DoE submitted that correspondence was sent to the incorrect address due to a lack of formal notification that Harmony had changed her address. Counsel did not address the evidence that the school was in fact aware that Harmony was no longer residing at the address retained in their administration system.
In my view the recommendation calls for consideration of a policy which would ensure proper consideration is given to the real circumstances existing for a suspended student living in chaotic conditions as Harmony did.
Recommendation ten That the DoE engage with the death of Harmony in considering the use of suspensions on children in circumstances similar to those experienced by Harmony, and that Harmony’s case be developed as a case study for the training of DoE staff on the impact of suspensions on school connectedness.
Counsel for the DoE submitted that although Harmony’s case could be developed into a case study, there are pre-existing training modules and case studies on suspensions and school connectedness, and schools should be able to exercise their discretion in that regard.
I am of the view that Harmony’s case would be a powerful training case study. However, given that I am unaware of the content of the pre-existing modules and case studies on suspension and school connectedness that Counsel for DoE refers to, it is difficult to be too prescriptive. For that reason I ask DoE to provide these findings to the relevant training authority for consideration and make the following amended recommendation: That the DoE consider using Harmony’s experience as a case study for the training of DoE staff on the impact of suspensions on school connectedness.
Findings and Recommendations
Date of death Harmony died on 14 January 2020.
Place of death Harmony died in the bathroom of room 26, Cundle Motor Lodge, Cundletown NSW.
Cause of death Harmony died by hanging.
Manner of death Harmony’s death was self-inflicted in the circumstances of longstanding neglect, family violence and school disengagement.
Recommendations pursuant to section 82 Coroners Act 2009
To the Department of Communities and Justice (DCJ)
To the Department of Education (DoE)
That DoE consider prioritising the redesign of the HSLP as a matter of urgency, taking into account the Home School Liaison Program Draft Report and the findings of this inquest.
That the DoE review its current suspension policy as to whether it adequately addresses the needs of children and young people experiencing abuse, neglect and homelessness, including the need for suspensions to be carried out in places external to the home environment when that environment presents a risk.
That DoE give consideration to amending the suspension policy to mandate consideration of the impact of school holidays when setting a suspension period.
Particular consideration should be given to using the commencement of a new term as a reset wherever possible.
student would otherwise have resided with continues, and if not, who is responsible for engaging with the student during the period of the suspension.
Conclusion
I offer my sincere thanks to Counsel assisting Gillian Mahony SC and to her instructing solicitors Kathleen McKinlay and Alexis McShane for their very great assistance in this matter.
I thank the OIC, Detective Senior Constable Nathan Gibson for his thorough investigation and ongoing assistance in these proceedings.
I recognise the many difficulties that Harmony and her family faced, including substance use, homelessness and family violence. As a community we were unable to keep them safe or provide the necessary support for them to keep Harmony safe. A coroner has no power to direct Government resources, only the ability to make recommendations and make public stories such as Harmony’s in the hope that it may spur action.
Finally, once again I offer my sincere condolences to all those who loved Harmony. I know she will not be forgotten.
Magistrate Harriet Grahame Deputy State Coroner, NSW State Coroner’s Court, Lidcombe 3 March 2025
30 September FFCC grant sole PR to Richard in respect off Tab 72A, p. 3; Tab 74, 2013 Harmony and Alex. p. 47 54 Susan granted supervised fortnightly visits. Susan’s ‐ partner prohibited from being alone with children.
Susan was not allowed to have the children until she could provide 12 months of drug free urine tests.
Orders never varied.
5 May 2016 School Counsellor contacted by SH requesting Tab 43, pp. 3, 24 information as to Harmony’s progress at school.
7 May 2016 Harmony attains 12 years of age.
10 May 2016 School Counsellor contacted by GJ re concerns as Tab 43, pp. 3, 22 to Harmony.
16 June 2016 Harmony attends school counselling session Tab 43, pp. 3 following request from classroom teacher and desire from Harmony.
1 July 2016 Harmony visits Susan during school holidays. Tab 7, p. 5; Tab 43, p.
Children not returned. Harmony later reports “was 12; Tab 72A, p. 4 tricked into relocating.” Harmony reported to be turning up at school in oversized clothing and unclean and Susan banned from going into Vinnies or other charity shops.
Report to DCJ that Susan was intoxicated when Tab 72A, p. 4 enrolling Harmony at School 2 or under a disability as confused, lack of clarity of thought and slurring her words.
16 July 2016 Helpline report screened in with response priority of Tab 73B, p. 163 167 10 days (less than 10 days). Allocated to Child Protection worker. ‐ 3 August 2016 GJ telephones DCJ to report Alex and Harmony’s Tab 7 at [32] [33]; living arrangements and the Court orders. Reported Tab 72D, pp 7 11 children missed 13 days of school so far that year. ‐ DCJ report they are reluctant to intervene. ‐ 8 August 2016 Susan applies for non local primary school Tab 47, p. 1 enrolment for Harmony.
‐ 12 August 2016 Helpline report to DCJ. DCJ informed of conditions of Tab 72D, p. 13 17 court order allowing Susan to see the children.
‐ 16 August 2016 Harmony and Alex screened by DCJ for neglect: Tab 72D, p. 19 25 Helpline report to DCJ. DCJ informed of Susan appearing substance affected, Harmony attending ‐ school unclean and in clothes too large for her and being provided with a uniform by the school and having no packed lunch for last 2 weeks.
DCJ document current family court orders state Tab 72D, p.
Susan should not have custody of Harmony.
Report NSW Police aware of orders and report 27 Tab 72D, Harmony is a “missing” child but support enrolment at school so they know where Harmony is located.
p. 29 A further helpline report is made to DCJ. Tab 72D, p. 19 17 August 2016 School counsellor reports as follows: Tab 43, p. 20 “DP has notified appropriate agency given an AVO is in existence regarding contact with mother. It appears no action has been taken to date.
DP reports that Harmony is presenting at her new school dishevelled and without food. These issues have been taken up by new principal and the school is supporting Harmony”.
16 August 2016 Helpline reports screened in with Tab 72D, p. 27 response priority of 10 days (less than 10 days).
22 August 2016 DCJ WAM: Discussion re risk of significant neglect. Tab 72D, p. 36 Decision “hold over to following WAM”.
31 August 2016 Helpline referred by DCJ to Weekly allocation Tab 72D, p. 35 Meeting.
7 September 2016 DCJ WAM re: consideration of previous meeting. Tab 72D, p. 37 14 September DCJ WAM decision: Close for competing priorities. Tab 72D, p. 38 2016 DCJ close Helpline Report as it “is not able to respond to this report”.
21 October 2016 Harmony enrolled at School 2 (previously a shared Tab 43, p. 19 enrolment with School 1 from 10 October 2016).
School requests Guidance File from School 1.
1 November 2016 School 1 school counsellor notified School 2 of need Tab 43, p. 15 to follow up with Harmony “early” regarding “risk of harm”, “peer relationship difficulties” and “child protection concerns”.
11 November School 1 school counsellor followed up with School Tab 43, p. 15 2016 3 who report “already aware” of matters raised on 1 November 2016.
31 January 2017 Email from , Learning Support Tab 45, p. 4 Teacher to noting “Harmony may not have any books. … had to give her a uniform as her mum wouldn’t buy her one….hers is one of the worst cases she has seen”.
8 February 2017 Harmony’s adverse in class behaviour documented. Tab 50, p. 3 9 February 2017 Harmony’s adverse in‐class behaviour documented. Tab 50, p. 4 14 February 2017 Harmony’s adverse in‐ class behaviour documented Tab 46, p. 6 self harms – scratches mouth until it bleeds.
Required to leave clas‐s.
‐ ‐ Harmony referred to Wellbeing Teacher for wellbeing check.
15 February 2017 PAT testing – Harmony (age 12 years 9 months) Tab 43, p. 56 reading age 8 9 years.
Harmony’s ad‐verse in class behaviour documented. Tab 46, p. 6 16 – 17 February Harmony absent from ‐school – unexplained. Tab 49, p. 1 2017 20 February 2017 Harmony’s adverse in class behaviour documented. Tab 46, p. 6 Nathan and Susan contacted.
‐ Harmony placed on detention.
22 February 2017 Harmony reports to PDHPE that she did not own the Tab 46, p. 6 required shirt. Sent to office and refused school shirt.
24 February 2017 Harmony’s adverse in class behaviour documented. Tab 46, p. 6 3 March 2017 Harmony’s adverse in‐class behaviour documented. Tab 46, p. 5 6 6 March 2017 Harmony given an in‐school separation for on going Tab 46, p. 5 ‐ disobedience.
‐ ‐ Harmony spoken to by school psychologist. Harmony Tab 43, p. 4 declined access to school psychologist.
10 March 2017 Harmony absent from school – unexplained. Tab 49, p. 1 16 17 March Harmony absent from school – unexplained. Tab 49, p. 1 2017 ‐ 20 March 2017 Harmony’s adverse in class behaviour documented. Tab 46, p. 5 ‐
22 March 2017 Harmony absent from school – unexplained. Tab 49, p. 1 24 March 2017 Harmony reports to PDHPE that she did not own the Tab 46, p. 5 required shirt. Assaults a teacher. Harmony reported for non compliance and aggressive behaviour.
‐ Harmony placed on long suspension (20 school Tab 49, p. 1 days) for physical violence.
27 March – 5 May Harmony suspended from school. Tab 49, p. 1 2017 7 May 2017 Harmony attains 13 years of age.
8 – 17 May 2017 Harmony absent from school – unexplained. Tab 49, p. 1 10 May 2017 Behaviour Analysis of Harmony conducted by Tab 45, p. 16 school.
Report made to Helpline re family fleeing domestic Tab 73A, p. 38 violence.
18 May 2017 Meeting with Harmony, Nathan and Susan. Tab 46, p. 5 Meeting ceased due to Nathan’s verbal abuse.
Susan and Harmony later return and suspension resolved.
Harmony’s adverse in school behaviour Tab 46, p. 5 documented.
22 May 2017 Harmony’s adverse in‐school behaviour Tab 46, pp. 4 5 documented.
‐ ‐ 24 May 2017 Harmony’s adverse in school behaviour Tab 46, p. 4 documented.
23 – 26 May 2017 Harmony absent from ‐school – unexplained. Tab 49, p. 1 29 May 2017 Harmony offered support – declined. Reports being Tab 43, p. 4 unmotivated and unhappy at school.
30 May – 1 June Harmony absent from school – unexplained. Tab 49, p. 1 2017 6 June 2017 Harmony reported for uniform violation. Tab 46, p. 4 7 June 2017 Harmony reported for uniform violation. Tab 46, p. 4 8 June 2017 Harmony reported for uniform violation. Tab 46, p. 4 Harmony’s adverse in class behaviour documented. Tab 46, p. 4 ‐
9 June 2017 Harmony reported for uniform violation. Tab 46, p. 3 4 ‐
13 June 2017 Harmony absent from school – unexplained. Tab 49, p. 1 14 June 2017 Harmony reported for uniform violation. Tab 46, p. 3 15 June 2017 Harmony reported for uniform violation. Tab 46, p. 3 16 June 2017 Harmony absent from school – unexplained. Tab 49, p. 1 19 June 2017 Harmony reported for uniform violation. Tab 46, p. 3 20 June 2017 Harmony absent from school – unexplained. Tab 49, p. 1 21 June 2017 Harmony’s adverse in school behaviour Tab 46, p. 3 documented. Harmony to continue isolation in senior class if undesir‐able behaviour continues.
23 June 2017 Harmony’s adverse in school behaviour Tab 46, p. 3 documented.
26 June 2017 Harmony’s adverse in‐school behaviour Tab 46, p. 2 documented.
Susan spoken with by‐ school – told not to send Tab 46, p. 2 Harmony to school until a meeting occurs with her.
27 June 2017 Harmony attends school – was told to wait outside Tab 46, p. 2 until 9.30am meeting finished. Harmony told teacher "Fuck this shit I am going" and she left the school premises.
Susan could not be contacted.
Alex spoken to let him know that Harmony is not to come to school next day.
Paperwork sent‐ home by mail for 4 school day suspension.
27 June – 30 June Harmony on short suspension for Continued Tab 51, p. 2 2017 Disobedience.
16 July 2017 Harmony reported to have left home late at night Tab 21(D), p. 11 12 and hitched ride to Mid-North Coast, NSW.
Tab 23 at [54] Passerby took Harmony to Taree Police Station. ‐ Police unable to contact Susan or Nathan.
Helpline report made to DCJ re: Harmony running Tab 73B, p. 163 168, away and Susan not taking protective steps. 171 ‐ 12.30am – Police drive Harmony back to home with Tab 21(D), p. 12 Susan and Nathan.
17 July 2017 16 July 2016 Helpline report case closed due to Tab 73B, p. 174 176 competing priorities.
‐
18 – 21 July 2017 Harmony absent from school – unexplained. Tab 49, pp. 1 2 ‐ 24 July 2017 Harmony’s adverse in class behaviour documented. Tab 46, p. 2 1 August 2017 Mandatory report made for Alex and Harmony. Tab 72E, pp. 37 41; ‐ Reports of violence between Susan and Nathan in Tab 73B, pp. 177 front of Harmony and Alex. Report of Nathan 190 ‐ chasing Susan with an axe, and children being hit ‐ by Nathan and Susan.
2 August 2017 1 August report screened for priority response within Tab 72E, p. 42; Tab 3 days (72 hours) 73B, p. 195 Harmony reported by teacher for uniform violation Tab 46, p. 1 4 August 2017 Harmony’s adverse in class behaviour documented. Tab 46, p. 1 ‐ 5 August 2017 DCJ acknowledge mandatory report of 1 August Tab 47, pp. 19 20 2017.
Harmony reported to have left home after Tab 47, p. 24 ‐ experiencing ongoing physical abuse by her brother (Alex) and Nathan, and mother fails to intervene.
Harmony reports leaving home and staying with a Tab 47, p. 24 friend.
7 August 2017 Harmony staying with a friend. Tab 47, pp. 24 25 Harmony reports homelessness to School. Reports Tab 42, p. 1; Tab 47, ‐ violence against her in the home and expresses pp. 24 25 preference to return to care of PGP on Central Coast. Principal was following up with further action. ‐ Harmony’s adverse in class behaviour documented. Tab 46, p. 1 HelpLine Report to DC‐J – ASM 25934363 – Tab 72E, pp. 50 55; screened for “risk of significant physical abuse” Tab 73B, pp. 215 with a PRF of “domestic violenc‐e” and “symptoms 235 ‐ of significant psychological harm. Report includes ‐ “last week mother presented to school with a major black eye and bruises all over her face. The mother said she got into a fight with the father. Harmony continues to run away due to her parents fighting.
Harmony refuses to go home today, Harmony hitchhikes and sleeps on the street. The mother does not intervene when Alex and the father abuse Harmony. When Alex tipped Harmony off a chair and tried to hit her with it, the mother father and Alex laughed at her.”
School contact NSWPF (Taree) re concerns re Tab 23 at [50] Harmony, Susan’s observed black eye and concerns Nathan may attend the school.
DCJ WAM meeting – triage to contact school to see Tab 72E, pp. 59 60 if Harmony has any friends or family she can stay with the night. ‐ Harmony identifies paternal step grandparents as where she wants to stay and will not return home. Tab 42, p. 1; Tab 47, pp. 24 25 ‐ 8 August 2017 DCJ contact SH who agrees for Harmony to reside Tab 72E, p.
with her and VH. Family arrangement approved by 61 Tab 72C, DCJ. Harmony transported to DCJ Office by school and collected from office by grandparents. p.41 No further role identified for DCJ.
9 – 24 August Harmony absent from School 3 – unexplained. Tab 49, p. 2 2017 Letter from FACS, Taree CSC, confirming 14 August 2017 Tab 47, p. 26 Harmony “left her home address and self placed with her step grandparents on 8 August 2017.
Expect placement to be permanent and for Harmony to e‐nrol in school at [Central Coast,
21 August 2017 Harmony commences at School 4. Tab 54, p. 2 Harmony becomes friends with Olga (daughter of Tab 34 at [3] Rachel) through attending School 4.
29 30 Harmony suspended for two days from school. Tab 51, p. 3; Tab 54, August 2017 p. 4 ‐ 16 October 2017 Report to NSWPF regarding Harmony bullying Tab 23 at [44] student at school.
25 October 2017 Susan, Nathan and Alex attempt to take Harmony Tab 72E, p. 80; Tab from school. Prevented by School Principal, 73B, p. 276 Teacher 6 based on FCA orders.
School provides DCJ copy of Family Law Court Tab 72E, pp. 84 91; orders.
Tab 73B, pp. 261 268 ‐ ‐ SH and VH contacted by DCJ. Assistance Tab 72E, pp. 72 75 requested from DCJ.
‐
DCJ contact paternal aunt who is “anxious to Tab 72E, p. 78 engage with any services that can assist [Harmony] and help secure her placement with the p/gps in the long term”.
26 October 2017 Paternal aunt and grandparents relinquish care of Tab 72E, pp. 78 79 Harmony.
‐ Harmony placed at Woy Woy Children and Young Tab 72E, pp. 94 Person’s refuge.
30 October 2017 Harmony 13 years 5 months of age and in Year 7 at school.
DCJ recommend and approve closure of file.
30 October 2017 Report to NSWPF regarding Harmony bullying Tab 23 [39] student at school.
2 November 2017 NSWPF officers attend Harmony at refuge to speak Tab 23 [39] informally about bullying complaint.
Harmony suspended from school. Tab 54B, p. 1 23 November Harmony suspended for two days from school. Tab 54B, p. 1 2017 Letter to VH and SH from School 4 re: suspension. Tab 51, p. 4 25 November Harmony leaves refuge through bedroom window Tab 73B, p. 294 2017 between 11pm and midnight.
26 November Report to NSWPF of Harmony (13 years) missing Tab 23 at [31] 2017 since last night. Person reported suggested no real concerns so recorded as “occurrence” only.
Helpline report made re: Harmony leaving youth Tab 72E, p. 95; Tab refuge at night and not returning. Speculation 73B, pp. 293 297 going to live with Susan and Nathan “who there are orders against due to safety concerns”. ‐ Missing Person Report made.
Triage notes conclude “Since it is not known whether she is currently in the care of her mother and partner there are no safety concerns known.” 8 December 2017 NSWPF add to report of 26/11/2017. Harmony Tab 23 at [32] believed to be in Qld with Susan.
22 27 Harmony subject of suspension for continued Tab 46, p. 19; Tab 49, February 2018 disobedience. p. 3 ‐ 28 February 2018 Harmony’s in school adverse behaviours Tab 46, p. 19 documented.
1 March 2018 Harmony’s in‐school adverse behaviours Tab 46, p. 19 documented.
5 March 2018 Harmony abse‐nt from school – unexplained. Tab 49, p. 3 7 March 2018 Harmony absent from school – unexplained. Tab 49, p. 3 9 March 2018 Harmony’s in school adverse behaviours Tab 46, p. 18 documented.
13 14 March 2018 Harmony’s in s‐chool adverse behaviours Tab 46, p. 18 documented.
‐ ‐ 15 March 2018 Harmony absent from school – unexplained. Tab 49, p. 3 26 March 2018 Harmony’s in school adverse behaviours Tab 46, p. 18 documented.
28 29 March Harmony abs‐ent from school – unexplained. Tab 49, p. 3 2018 ‐ 3 5 April 2018 Harmony’s in class adverse behaviours documented. Tab 46, p. 17 ‐ ‐ 10 April 2018 Harmony’s in class adverse behaviours documented. Tab 46, p. 16 11 – 13 April 2018 Harmony absent from school – unexplained. Tab 49, p. 3 ‐ 1 – 8 May 2018 Harmony absent from school – unexplained. Tab 49, p. 3 7 May 2018 Harmony attains 14 years of age.
10 May 2018 Harmony’s in class adverse behaviours documented. Tab 46, p. 16 11 May 2018 Harmony refused to attend class. Nathan Tab 46, p. 15 ‐ contacted who spoke with Harmony. Harmony crying after call.
14 May 2018 Harmony’s in class adverse behaviours documented. Tab 46, p. 15 18 May 2018 Harmony in class adverse behaviours documented. Tab 46, p. 15 ‐ ‐ 24 May 2018 Harmony using a box cutter to cut her own legs. Tab 46, p. 14 28 May 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 14 ‐ Harmony given uniform violation. Tab 46, p. 14 31 May 2018 Harmony given uniform violation. Tab 46, p. 14
6 June 2018 Harmony’s adverse in class behaviours documented Tab 46, p. 14 including lighting a girl’s hair.
‐ 12 June 2018 Harmony reported by other students to have a zip Tab 46, p. 13 lock bag of marijuana at school.
‐ Harmony’s adverse in class behaviours documented. Tab 46, p. 13 14 June 2018 Harmony absent from school – unexplained. Tab 49, p. 3 ‐ 18 June 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 13 19 June 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 13 ‐ ‐ 20 June 2018 Harmony seen crying at canteen tables and Tab 46, p. 12 approached by teacher. Refused support.
Harmony’s adverse in class behaviours documented. Tab 46, p. 13 ‐ 21 June 2018 Harmony given uniform violation. Tab 46, p. 12 22 June 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 12 ‐ Harmony given uniform violation. Tab 46, p. 12 25 June 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 12 ‐ Letter to Susan from School 3 re: suspension of Tab 51, p. 6 Harmony.
26 – 29 June 2018 Harmony subject of suspension for continued Tab 49, p. 3 disobedience.
2 – 6 July 2018 Harmony absent from school – unexplained. Tab 49, p. 3 25 July 2018 Tab 23, p. 53 Harmony called NSWPF to report Nathan for assaulting Susan. Police fail to report it to DCJ.
Harmony and Susan attend school for return from Tab 47, p. 30 suspension meeting. Susan presents with “very red, purple swollen hand and some cuts/bruises on her face”.
Harmony given uniform violation. Tab 46, p. 11 Harmony spends the night at a sporting field Tab 73B, pp. 376, 432 in Mid-North Coast, NSW, sleeping rough.
Harmony’s adverse in class behaviours documented. Tab 46, p. 11 ‐ 65
26 July 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 11 KK1 and her dau ‐ ghter (school friend of Tab 30 at [6]; Tab Harmony) meet Harmony at sports field in Mid72A, p. 5 North Coast, NSW and take her back to their home.
Tab 30 at [7] Harmony observed to have numerous bruising to her face and body.
NSWPF receive report Harmony asked to leave Tab 23 at [27] her home due to be being unsafe.
DCJ receive report Harmony unable to be at home Tab 73B, p. 340 due to DV perpetrated by Susan and Nathan.
Harmony’s adverse in class behaviours documented. Tab 46, p. 11 ‐ 27 July 2018 Harmony given uniform violation. Tab 46, p. 11 Harmony’s school receives phone call from KK Tab 47, p. 30 reporting Harmony out of home and exposed to violence in her home. Harmony confirms she cannot return home.
School makes mandatory report: 11993543. Tab 73B, p. 340 DCJ receive ROSH Report (ASM 3298772); NH Tab 73B, pp. 350, 361 237049 re: Harmony. “ROSH report on 27/07/2018 (ASM 3298772) Screened in for ‐symptoms of ‐ psychological harm as 14 year old Harmony has self pl‐aced with a friends family due to being fearful of staying at home. Child Story reveals a pattern of domestic violence within the household, which results in Harmony running away and the reported information indicates that domestic violence is likely to be occurring in the household currently based on the mother’s recent presentation with injuries and Harmony’s behaviour. There are also concerns that the violence at home is causing school absence for Harmony. Although the reported information indicates that Harmony is currently safe, the care arrangements do not appear to be safe or long term.” 27 July 2018 Harmony’s adverse in class behaviours documented. Tab 46, p. 11 30 July 2018 Harmony placed on in‐school separation (which Tab 46, p. 11; Tab 47, occurred on 31 July 2018). p. 33 ‐
1 KK places it in late March 2018 but contemporaneous documents suggest was 26 July 2018
31 July 2018 Mandatory Report made by School – No. 11998826. Tab 73B, p. 339 344 Report to DCJ (ASM 3301409) – screened in as Tab 73B, p. 350 ‐ “No Parent/Carer Available/Willing/Able to Provide Care” re report that H‐armony is reported to have been asked by her mother Susan to leave the family home as Harmony is not safe there.
Harmony has then stayed with friends, but this is not a long term solution to her living situation”.
Harmony reports no longer staying at KK’s home. Tab 21(I), p. 58 Harmony taken to Taree Police Station and indicates she would stay “in the park”.
KK contacted and agreement made for Harmony to stay at her home.
KK came to school and said she did not want Tab 47, p. 33 Harmony to come to their place.
School tried unsuccessfully several times to contact SM. School contacted the Child Wellbeing Unit who advised to contact Taree Police.
School spoke to Taree Police.
School rang KK at 4.05pm. She had Harmony with her and was taking her to Taree Police.
Harmony taken to Police Station. KK agrees for Tab 23 at [28] Harmony to stay the night. Police make mandatory report to DCJ: No: 11998756.
Harmony given uniform violation. Tab 46, p. 11 1 August 2018 Harmony given uniform violation. Tab 46, p. 11 2 August 2018 Adverse behaviour of Harmony reported. Tab 46, p. 10 “Harmony went home”. Susan called to school.
DCJ inform school “in process of contacting youth Tab 47, p. 35 refuges – to find somewhere for [Harmony] to stay.
Harmony given uniform violation. Tab 46, p. 10 5 August 2018 Harmony leaves home following reported physical Tab 11, p. 28 abuse by Nathan and Alex.
6 August 2018 Harmony given uniform violation. Tab 46, p. 9
Harmony’s adverse in class behaviour documented. Tab 46, p. 9 Letter to Susan re: ‐Harmony subject to short Tab 51, p. 7 suspension for continued disobedience between 7 and 10 August 2018.
7 10 August Harmony suspended from school. Tab 49, p. 3 2018 ‐ 8 August 2018 Report to DCJ by KK re: concerns about Harmony. Tab 73B, p. 376 377 Seek support from DCJ for a long term case plan for Harmony and assistance to purchase clothing for ‐ Harmony, school uniform and school belongings.
13 August 2018 DCJ Meeting re: Harmony’s circumstances. Notes Tab 72G, p. 210 “Refuge cannot care for Harmony as she is 14 years old. Harmony has returned to school School 3.
‐ School Psychologist calls for Harmony to attend Tab 43, p. 4 office – Harmony does not attend.
Harmony given uniform violation. Tab 46, p. 9 15 August 2018 School note refers to contact with Tab 47, p. 36 (FACS) – open case plan, will support her to find other carers.
20 August 2018 Harmony’s adverse in class behaviour documented. Tab 46, p. 8 21 August 2018 Harmony absent from school – unexplained. Tab 49, p. 3 ‐ 22 August 2018 Harmony’s adverse in class behaviour documented. Tab 46, p. 8 24 August 2018 DCJ Alternate Assessment – Harmony verbalises Tab 73B, pp. 392 410 ‐ she does not feel safe in Susan’s home due to the violence. ‐ Notes reporter found Harmony at sports field in Mid-North Coast, NSW and brought her home to stay with her family.
Refers to care provided by community member.
28 August 2018 Harmony’s adverse in class behaviour documented. Tab 46, p. 8 ‐
29 August 2018 Helpline Report re Harmony: “Homeless – cannot Tab 47, p. 38 return home due to domestic violence and drug usage Harmony has not been home for 5 weeks.
FACS were notified of this 5 weeks ago”. Report also includes report that Harmony cutting herself during class and where she was residing.
Plan for Harmony to attend school on 30 August 2018 with all her belongings as short term accommodation broken down.
30 August 2018 Harmony’s adverse in class behaviour documented Tab 46, p. 8 ‐ Harmony moves to PGF GJ’s house at Central Coast. Tab 73B, p. 453 30 August – 17 Harmony absent from school – marked as Tab 49, pp. 3 4 September 2018 unjustified, however School 3 aware that Harmony had moved to Central Coast NSW ‐ pending enrolment in a local school.
7 September 2018 Alternate Assessment (SARA Exception) Tab 73B, p. 407 conducted by , DCJ. Bruising (under makeup) observed on Susan’s face during assessment process.
DCJ close helpline report on basis Harmony Tab 73B, p. 453 “now residing with [grandparents] whilst her father is in rehabilitation”.
DCJ sign letter confirming Harmony commenced Tab 73B, pp. 454 455 living with GJ at Central Coast, NSW on 30 August 2018 under an informal family ‐ arrangement. Harmony deemed unsafe to return to her mother’s home and notes FCA orders.
c. 17 September Harmony enrolled in Yr 8, School 4. School 4 2018 Records 3 October 2018 , Taree DCJ contact GJ and PJ asking Tab 7 at [37] [38]; if they would look after Harmony and stating Tab 73B, pp. 409 Harmony had been subject to violence and had 411 ‐ been sleeping in a park. ‐ GJ and PJ travel to Taree to collect Harmony and return with Harmony to Central Coast, NSW.
October 2018 Richard located in a rehabilitation centre. Tab 7 at [36]; Tab 73B, p. 421 October 2018 Harmony commences work at “The Petal Sisters” Tab 6 at [33]; Tab 7 at Florist in Ettalong – every Saturday morning. [47]
Late 2018 Harmony undertakes work experience at "Serenity" Tab 6 at [34]; Tab 7 at as beautician.W orked there 1 day/ week. Offered [46] and engaged in, school holiday employment.
20 December Nathan assaults Susan in the street witnessed by Tab 738,p p. 469-474 2018 Alex. Police called and Nathan charged. Police Tab 72G, p. 24 report records "Nil" family law orders.
26 - 27 December Harmony stays at Rachel's house with permission Tab 33 at [7] 2018 of PJ and GJ.
28 December 6pm -Rachel drops Harmony at GJ and PJ's house. Tab 33 at [7] 2018 31 December GJ and PJ host NYE party. Harmony tried to go to Tab 6 at [38]; Tab 7 at 2018 score drugs and drink alcohol - not permitted by [48]
2019 2019 DCJ Practice Framework and Group Supervision Tab 73a, p. 55 introduced.
1 January 2019 Harmony leaves GJ and PJ's home and stays with Tab 6 at [39] school friend, Olga.
Early Richard discharged from rehab -returns to cabin on Tab 6 at [41]; Tab 8 at January mother's property. [30] 2019 January 2019 Harmony moves in with Richard. Stays for about 6 Tab 6 at [42] weeks.
12 February 2019 Letter to GJ from School 4 re: suspension of Tab 51,p . 8 Harmony.
PJ informs School 4 that Harmony now living with Tab 47, p. 41 Richard at Central Coast, NSW.
13 - 14 February Harmony subject of suspension for continued Tab 51,p . 8 2019 disobedience.
22 February 2019 Letter from School 4 to Richard re: suspension of Tab 51,p . 9 Harmony.
22 - 26 February Harmony subject of suspension for continued Tab 51,p . 9 2019 disobedience.
27 February 2019 Harmony ingests 5 -6 of her father's anti-depressan Tab 6 at [42]; Tab 41, C. midday medication. Found staggering at school. Ambulance pp.5,63
called. Harmony transported via ambulance and admitted to Gosford Hospital.
1 March 2019 Harmony discloses Nathan was physically abusive Tab 41, p. 64 to Susan which is why she left the home.
Mandatory report made by School 4. Tab 73B, p. 549 5 March 2019 DCJ informed Harmony refusing to be discharged to Tab 73B, pp. 529 534 her father’s care. Risk of significant harm reported for Harmony being cared by her father. Reports ‐ remains extremely angry at father’s past drug use.
Assessed as being at chronic risk of harm through misadventure due to risk taking behaviours and vulnerability.
Harmony identifies friend (Olga) as person she could be discharged to.
6 March 2019 Harmony remains adamant will not stay with Richard. Tab 33 at [10]; Tab 41, pp. 70 71 Harmony contacts Rachel who offers for Harmony to stay with her.
‐ Harmony discharged to Rachel’s care. Harmony had all her belongings.
7 March 2019 DCJ informed Harmony to be discharged into Tab 41, p. 73 Rachel’s care.
8 March 2019 Harmony has issue at school. Rachel provides Tab 33 at [11] consent for Harmony to walk home from school following an issue.
School contacts DCJ and requests someone collect Tab 73B, pp. 591 592 Harmony. DCJ inform school they will not collect Harmony as they do not have PR and she lives with ‐ Rachel with knowledge of family.
School 4 contacts Woy Woy Youth Refuge for a Tab 73B, p. 592 placement and arranges for refuge to collect Harmony from school.
21 March 2019 Harmony subject of School Incident report re: Tab 47, p. 43 request to update her contact details. Harmony Tab 57Gp. 1 retorted “it’s the schools fault I’m in a fucking refuge”.
Letter to Richard from School 4 re: suspension of Tab 51, p. 10 Harmony.
22 – 27 March Harmony subject of suspension for continued Tab 51, p. 10 2019 disobedience.
5 April 2019 Letter to Richard from School 4 re: suspension of Tab 51, p. 11 Harmony. Woy Woy Youth Refuge report suspension was for swearing at staff.
School requires Harmony to attend school counsellor as a condition of her return which Harmony refused.
5 April – 16 May Harmony subject of suspension for 20 school days Tab 51, p. 11 2019 for Persistent or Serious Misbehaviour.
10 April 2019 Woy Woy Youth Refuge inform DCJ that exit plan is Tab 73B, p. 510 for Harmony to transition to Rachel’s home which is described as a “good placement option and a favourable outcome for Harmony in terms of her ongoing care and support”.
23 April 2019 Rachel informs Harmony she was always welcome Tab 33 at [12] to stay with her.
Harmony informs Woy Woy Youth Refuge that her Tab 72A, p. 8 mother is coming to collect her.
24 April 2019 Harmony leaves Woy Woy Youth Refuge. Tab 73B, p. 596 7 May 2019 Harmony attains 15 years of age.
8 May 2019 Woy Woy Youth Refuge inform DCJ Harmony no Tab 72A, p. 8; Tab longer a resident and self placed with her mother. 73B, p. 596 9 May 2019 DCJ recommend closure as Harmony in the care Tab 73B, p. 596 ‐ of her mother and “need for accommodation has been satisfied. There appears no further need for FaCS involvement at the present time and closure is recommended”.
15 May 2019 Susan applies for financial assistance from School Tab 45, p. 20 3 for Harmony’s uniform noting “just declared bankrupt & lost family home”.
21 May 2019 Teacher 1, Principal of School 3, seeks advice on Tab 49, p. 8 Harmony’s failure to attend. Notes schools knowledge that orders state not to be with Mum but was advised to take her so “we knew where she was”.
21 22 May 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 ‐ ‐
24 May 2019 Harmony punched in the head multiple times by Tab 46, p. 22 another student (3 punches observed by teacher).
Tab 30 at [21] Teacher broke up the fight. Harmony left school grounds.
KK collects Harmony from local Library and Tab 30 at [19] takes Harmony to KK’s home. Treat’s Harmony’s face with ice packs.
Harmony returns to Mt George that afternoon by school bus.
Response received by school from DoE Child Tab 47, p. 46 Protection Services to mandatory report, seeking further information.
School makes mandatory report: No: 12442152. Tab 47, p. 66 CWU recommended referring Harmony’s case to Tab 57(i) p. 12 the HSLO due to her habitual non attendance.
28 May 2019 Child Protection Unit of DoE sets o‐ut Tab 47, p. 48 recommendations to mandatory report.
School reports Harmony “Victim in a fight on Friday Tab 45, p. 9 has not returned this week so far. CWU notification. Offering TAFE taster courses. Refused ‐to engage with Meg”.
29 May 2019 School counsellor offered support to Harmony who Tab 45, p. 11 was “unmotivated” about this.
30 May 2019 School counsellor attempt to engage with Harmony – Tab 42, p. 1 Harmony absent from school.
27 May – 7 June Harmony non attendance at school (unexplained). Tab 49, p. 5 2019 ‐ 6 June 2019 DCJ note there is no open case for Harmony on Tab 73B, p. 677 ChildStory.
DCJ close case on basis Harmony is 15 years old, choosing to reside with her mother and can return to her paternal grandparents home should she choose.
DCJ recommend referral to Manning Support Services (MSS) to support Harmony if she chooses to stay in the area. MSS can liaise with the school.
School counsellor attempt to engage with Harmony – Tab 42, p. 1 Harmony absent from school.
11 June 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 14 June 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 18 19 June 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 20 ‐June 2019 Harmony atte‐nds School counsellor but not wanting Tab 43, p. 6 to engage.
21 June 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 24 June 2019 School makes‐ mandatory report to DCJ as to Tab 42, p. 4; Tab 47, Harmony’s circumstances. Reports the home has p.55; Tab 57(i)[74] no electricity, running water or toilet facilities, and Harmony did not go home one night due to domestic violence.
24 25 June 2019 Harmony non attendance at school (unexplained). Tab 49, p. 5 ‐ ‐ 27 June 2019 DCJ report referral to HSLP ineffective as Tab 73B, p. 735 response is that Harmony is too old for HSLP support.
27 June – 2 July Harmony non attendance at school (unexplained). Tab 49, p. 5 2019 ‐ 2 July 2019 Meeting at school re: Harmony’s non attendance. Tab 49, p. 7 Scheduled 11.30am – no attendance by family.
‐ Susan arrives at 1.30pm. Given letter re: non Tab 49, p. 11 attendance.
‐ Letter from School 3 to Susan re: referral to the Tab 49, p. 11 Home School Liaison Program (HSLP).
Harmony reports to school she has nowhere to Tab 47, p. 56 sleep and may sleep rough at local nature reserve. Mandatory report made by school.
DCJ ask school to locate Harmony and make an offer of a swag and a room at the Presbyterian Church made.
3 July 2019 Harmony accepted onto HSLO caseload. Tab 57(i) [72] Teacher 5, HLSO allocated to Harmony’s HSLP Tab 49, pp. 14 15; case. Tab 56C; Tab 56D ‐ 4 July 2019 DCJ on notice Harmony not attending school and Tab 73B, p. 729 living with Susan and Nathan.
DCJ contact school who confirm Harmony was hit by a female student upon returning to School and now barely attends due to bullying.
22 July 2019 Harmony non attendance at school (unexplained). Tab 49, pp. 5 6 onwards ‐ ‐ 24 July 2019 Teacher 5 contacts school – advised that Harmony Tab 79, p. 12 has not returned to school after holidays (5 21 July 2019).
‐ 5 August 2019 Rachel deposits money into Harmony’s NAB Tab 33 at [13]; Tab account to facilitate transport for Harmony to Taree 33B, p. 11 train station and for a train ticket to Gosford.
6 August 2019 Harmony catches a train to Gosford and commences Tab 33 at [14]; Tab staying with Rachel. 33B, p. 12 22 August 2019 Susan confirms to DCJ Harmony not attending Tab 42, p. 5; Tab 72B, school and had left for the Central Coast. Susan and p. 746 Nathan living at Cundletown Motel.
School makes mandatory report (No. 12582326). Tab 47, p. 59 26 August 2019 Conversation between Rachel, Harmony and Tab 33 at [15]; Child Protection Helpline. Harmony discloses Tab 73B, pp.
Nathan physically abusive, Susan and Nathan 759 761 verbally abusive, daily pot use, no substantial nutrition provided and minimal attendance at ‐ school due to family issues.
Harmony states she wants to stay in her present accommodation. Rachel confirms she is happy for Harmony to stay on a permanent basis.
Harmony reports to CrimeStoppers of physical abuse Tab 72A, p. 9 by Nathan and threat of abuse should she return home.
27 August 2019 School reports “CWU notification. Mother reports Tab 55D, p. 2 that she has returned to the Central Coast”
7 September 2019 , Taree CSC prepares letter confirming: Tab 73B, p. 454
Harmony is not a child in care or subject to ongoing FACS intervention.
Harmony is legally under the parental responsibility of her biological father, Richard, who is currently in a rehabilitation facility and unable to provide care and protection.
Harmony has chosen to cease living with her mother, Susan, due to significant domestic violence in the home.
Family and Community Services has assessed that Harmony would be unsafe should she return to her mother's home, and there are Family Law Court orders (30/09/2013) prohibiting Susan and her partner from unsupervised access to Harmony unless certain conditions are met.
11 September Helpline transfer ROSH Report to CCMARC (15 Tab 73B, pp. 745 751 2019 days after it was received where given a “within 10 days response time). ‐ 26 September NSWPF received a Child at Risk report through Tab 10 at [6]; Tab 23 2019 Crimestoppers after Harmony reported being at [12] verbally harassed and threatened by Susan and Nathan.
Harmony was concerned that the threats of assault would be carried out, as she advised she had been assaulted by Nathan in the past.
1 October 2019 DCJ (CCMARC) discuss Harmony’s needs with Tab 73B, pp. 492 793 Rachel. DCJ informed of difficulties in accessing supports for Harmony including financial ‐ assistance, education and medicare support.
Harmony not enrolled at school as no documents to support an enrolment. Harmony sleeping on a blow up mattress in Olga’s room.
DCJ contact Rachel who confirms Harmony still in her care, Harmony wants to remain there and she is happy to continue to care for Harmony.
DCJ recommend Rachel return to Centrelink to seek what financial assistance may be available to her and Harmony.
DCJ informed Harmony unable to be enrolled in school as no identification.
DCJ make referral to Evolution Youth Service (AKA 2 October 2019 Tab 73B, p. 794 Coast Community Connections) and close triage record.
3 October 2019 DCJ close case following report made by Rachel Tab 73B, pp. 796 798 without assessment as “supports in place at the current time. No role for DCJ”. ‐ Rachel informed of decision. Send Rachel a referral form for Coast Community Connections.
c. 18 October Harmony leaves Rachel’s home following argument Tab 33 at [19] 2019 with Olga.
Tab 34 at [23] [24] ‐ 24 October 2019 Harmony ceases living with Olga following fall out Tab 33 at [19]; Tab 34 in friendship. at [22], [25] Police return Harmony to Rachel but she refuses Tab 23 at [7] and departs with the police.
NSWPF were unable to arrange refuge accommodation, so Harmony slept at the police station and driven to the train station the following morning.
Police complete C@R Incident – No ROSH outcome. Assessed by Child Wellbeing Unit of NSWPF – no ROSH outcome.
c. 25 October Harmony returns to live with Susan and Nathan at Tab 10 at [7] 2019 Cundletown Motel.
28 October 2019 Teacher 1 emails ., DoE, Tab 49, p. 13 attaching application for Home Schools Liaison Program.
29 October 2019 appointed as Harmony’s HSLO. Tab 49, p. 19 makes enquiries of Harmony’s location ‐ 3
9.30pm reports hearing make and female Tab 10 at [25] screaming “OMG, she turned blue not sure what to do”.
11pm Alex sends Harmony a snapchat message saying Tab 12, p. 3 goodnight.
11:30pm hears loud screams coming from a Tab 10 at [119] young person.
14 January 2020 Harmony takes her life.
Susan reports seeing Harmony on the fold out sofa in Tab 10 at [10] the loungeroom watching tv, before leaving to purchase cigarettes.
Susan says she was downloading the CommBank app for cashless withdraws.
1:23am Susan and Nathan left the motel and visited a CBA Tab 10 at [11], [145]; ATM in Taree, from which Susan withdrew money. Tab 35, p. 3 They visited a United Petroleum and purchased fuel, Tab 10 at [13], [60] cigarettes, Pepsi, Mountain Dew and a Dare (Away 20 minutes) espresso drink.
c. 1:43am Susan and Nathan returned to the motel. Tab 10 at [11], [145]; Tab 35, p. 17 Tab 10 at [13] [16] Susan and Nathan became concerned about Harmony, so they used a butter knife to manipulate ‐ the lock and gain entry to the bathroom.
(44 minutes between Upon entry, they saw Harmony hanging in the arriving and calling shower cubicle.
ambulance) Susan ran out of room to call 000.
(4 – 6 mins to die Nathan grabbed Harmony and removed the rope from hanging) from around her neck. He then commenced CPR.
2:27:32am First triple zero call was made by NOK The duration Tab 10 at [142]; Tab of call was 15 minutes and 35 seconds. 37 ‐ “the NOK is clearly hysterical and screaming "someone help me". She provided the address as Cundletown Motel and states "she has hung herself ... she is blue all over ... I do not know how long she has been dead she is not breathing she is only 15".
2:31am Paramedics receive call. Tab 27 at [4]; Tab 28 at [5]
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