Coroner
Deputy State Coroner Linton
Date of death
2022-08-12
Finding date
2025-05-05
Cause of death
terminal palliative care in a girl with a clinical diagnosis of aspiration pneumonia and cerebral palsy
AI-generated summary
A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence, presenting substance-affected whilst caring for her profoundly disabled daughter who required 24/7 supervision and assistance with all activities. Despite initial coordination of nearly 24/7 support workers in the home (2020-2021), HC's documented relapse into severe alcohol abuse and unauthorized use of her daughter's medications (particularly clonazepam) in early 2022 prompted placement in hospital then respite care. The removal was a difficult but necessary child protection decision; however, the clinical lesson is the challenge of balancing child safety against maternal mental health deterioration, particularly when parents face unrelenting caregiver burden. Better early respite provision, family-inclusive safety planning, and integrated addiction/mental health support may have prevented both deaths.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
[2025] WACOR 19 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 22 - 24 OCTOBER 2024 DELIVERED : 5 MAY 2025 FILE NO/S : CORC 2212 of 2022 DECEASED : Child HR FILE NO/S : CORC 1010 of 2022
DECEASED : HC Catchwords: Nil Legislation: Nil Counsel Appearing: Ms S Tyler and Ms T Weston assisted the Coroner.
Mr G Scott (SSO) appeared on behalf of the Department of Communities and the Child and Adolescent Health Services.
Case(s) referred to in decision(s): Nil
[2025] WACOR 19 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the deaths of HC (name suppressed) and Child HR (name suppressed) with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth on 22 to 23 October 2024, find that:
the identity of the deceased person was HC and that the death of HC occurred on or about 23 April 2022 at 14 Summerville Boulevard, Caversham as a result of traumatic head injury with combined drug and alcohol effect; and
the identity of the deceased person was Child HR and that her death occurred on 12 August 2022 at Perth Children’s Hospital, Nedlands, as a result of terminal palliative care in a girl with a clinical diagnosis of aspiration pneumonia and cerebral palsy in the following circumstances:
TABLE OF CONTENTS SUPPRESSION ORDER The deceased’s names are suppressed from publication. The deceased should be referred to as HC and Child HR in any external publication and no information should be published that might lead to the identification of Child HR.
Child HR was born a healthy baby girl on 22 April 2010. Sadly, when she was still a small baby she suffered an acquired brain injury that reportedly occurred when her mother, HC, fell asleep while breastfeeding her. As a result of the brain injury, Child HR was diagnosed with the most severe form of cerebral palsy and required care to support her in all aspects of her daily living.
For the majority of her life, that care was provided by her mother, HC, along with significant support from various care workers, teachers and health professionals. By all accounts, HC was a devoted mother to Child HR and did her best to provide a loving home environment that met all of Child HR’s needs. She was described as a beautiful girl with a contagious smile who was clearly very loved by her family and those who cared for her.
Unfortunately, HC was known to have issues with substance use and some mental health issues that, on occasion, interfered with her ability to provide the safe home and high level of care and supervision that Child HR needed. As a result of her mother’s substance use and mental health issues, the Department of Communities (Communities) had regular contact with Child HR and her mother during her life.
For the most part, Communities was able to address the concerns by periods of providing intensive family support and monitoring to help Child HR remain living at home with her mother.
In early 2022, the level of concern had escalated. Concerns were being raised with Communities from multiples sources that HC appeared to be regularly under the influence of alcohol, drugs and prescription medications and she was also in a violent new relationship, that was believed to be putting Child HR’s safety at risk, as well as her own. On 9 March 2022, Communities decided that it would apply to the Children’s Court for a protection order in relation to Child HR.
A Children’s Court Magistrate granted the order for Child HR to be placed in the care of the CEO of the Department of Communities. A similar order had been granted in the past and Child HR had then remained living with her mother, just with more supervision. This time, Communities was planning to instead place Child HR elsewhere, although she remained with her mother while the new placement was found.
On 19 April 2022, while a new plan was still being finalised, Communities reached the conclusion it was no longer safe for Child HR to live with her mother and intervention action was taken to remove Child HR from her mother’s home. Child HR was four days away from her 12th birthday when she was removed from her home. She was taken to Perth Children’s Hospital (PCH), where she remained at the hospital until 3 May 2022. Child HR’s usual support workers continued to support her in the hospital, but her contact with her mother was limited and supervised.
HC last saw her daughter at the hospital on 22 April 2022, which was her birthday.
The next day, HC’s mother went to HR’s home and found HR lying face down on the floor, unresponsive. St John Ambulance was notified and ambulance officers
[2025] WACOR 19 attended the home and confirmed HC had died. She appeared to have suffered a head injury, so a police investigation considered whether there were any suspicious circumstances surrounding her death. The police investigation ultimately ruled out any criminality, but left open whether HR had died by way of accident or suicide.
After HC’s death, Child HR was placed in a facility that supports children with complex needs, known as Harry’s House. Child HR lived at Harry’s House from 3 May 2022 until early August 2022, when she became increasingly unwell. She was transferred to PCH on 5 August 2022 where she was diagnosed with a lower respiratory tract infection. Her treating medical team felt that her condition was irreversible, on the background of her pre-existing health issues. After consultation with her next of kin, she was supported through the dying process with a focus on her comfort. Child HR died on 12 August 2022.
As Child HR was a child in care when she died, her death was a reportable death under the Coroners Act 1996 (WA) and a coronial inquest is mandatory. I am also required under the Act to comment on the supervision, treatment and care provided to Child HR while she was in care.
Concerns were raised by Child HR’s grandparents that the death of her mother, HC, was directly related to the removal of her daughter Child HR by Communities. They also believe that their granddaughter’s health was adversely affected by her mother’s untimely death. Child HR’s grandparents therefore submitted to the Court that any investigation into the death of Child HR should include a parallel investigation into the circumstances of HC’s death. Based upon the concerns raised by Child HR’s maternal grandparents, I exercised my discretion under s 24 of the Act and directed that an inquest be held into the death of HC.
Under s 40 of the Act, the State Coroner then directed that the death of Child HR and the death of her mother HC be investigated at one inquest, having regard to the potential connection between the removal of the child from the care of her mother and the death of her mother, as well as the possibility that the mother’s death may be relevant to the circumstances attending to the child’s death. Accordingly, I have considered it appropriate to consider the quality of the treatment, supervision and care provided to Child HR over a longer period, that encompassed her removal from her mother’s care, rather than simply focussing upon the final period leading to her death.1
This is a very sad and difficult case. I acknowledge from the outset the great loss that HC’s parents, who were also Child HR’s devoted grandparents, have suffered losing their last living child and their granddaughter within months of each other. While dealing with their own grief, they have been supporting their grandson, who has lost his mother and sister. They have attempted to seek answers for him, as much as for themselves. HC’s parents (whom I will also refer to at times in this finding as Child HR’s grandparents) have written eloquently about their concerns around what they perceive as the “unprofessional and unacceptably uncaring” attitude of Communities staff towards their daughter and their belief that more could have been done to 1 Exhibit 1, Tab 4.
[2025] WACOR 19 provide support and understanding to her. They believe this might possibly have prevented both deaths, or at least allowed their daughter to be with their granddaughter until Child HR’s death.2
Communities staff have provided significant information to the Court to explain the long and complex history of their engagement with HC and Child HR, and why they ultimately felt it was necessary to remove Child HR from her mother’s care for her safety, despite the acknowledged loving relationship between mother and child.
At the end of the inquest, a statement was read out from HC’s parents, which set out some of their reflections upon these sad events and their hopes for lessons that will be learned. I have given due regard to their questions and comments in completing this finding, acknowledging the devastating loss they have experienced and their genuine belief that if Communities’ staff had been more open in their lines of communication, both deaths may have been prevented, or at least delayed. I hope that they will understand after reading this finding how I have reached my conclusions, even though I acknowledge respectfully that they will likely not agree with all of them.
HC’s parents acknowledged that their daughter had “confronted some demons”3 in a letter they wrote to the Director-General of Communities after her death. In summary, HC had what she described as an “idyllic”4 upbringing on a farm, but when she was sent to a private boarding school to commence high school, she was unhappy and got into trouble, eventually being expelled. She began using illicit drugs and engaging in alcoholic binges from the age of 17 years. She also had a long history of anxiety and panic attacks and she was prescribed benzodiazepines and the anti-psychotic medication quetiapine to manage her symptoms. She was known to visit various doctors to obtain additional prescription medications, and also misused over the counter medications sometimes.5
HC had an older son, Z, who lived elsewhere when she had Child HR on 22 April
HC had been married twice before and was married to Child HR’s father when she was born. HC was Caucasian and Child HR’s father is Maori. Child HR’s father also has two daughters from a previous relationship, who lived elsewhere at the time Child HR was born.6
While still pregnant with Child HR, HC had been seen at a Community Mental Health Service due to antenatal concerns.7
Child HR was five weeks old when she sustained an acquired brain injury due to her mother falling asleep whilst feeding Child HR, resulting in accidental suffocation. It 2 Exhibit 1, Tab 11.
3 Exhibit 1, Tab 11.1, p. 1.
4 Exhibit 1, Tab 25, p. 2.
5 Exhibit 1, Tab 2 – 3.
6 Exhibit 1, Tab 2 – 3; Exhibit 2, Tab 9.1.
7 Exhibit 2, Tab 8.
[2025] WACOR 19 was deemed to be a tragic accident and no action was taken against her mother and, although the Child and Adolescent Health Service’s Child Protection Unit (CPU) were consulted, Communities and police did not become involved at the time.8
As a result of the brain injury, Child HR was diagnosed with the most severe form of cerebral palsy, Level V. She was unable to speak, eat or move independently and she was fed and administered medication through a combined percutaneous endoscopic gastronomy and percutaneous endoscopic jejunostomy (PEG/PEJ) tube, being a tube inserted in her abdominal wall for giving medications (PEG) and feeds (PEJ). Child HR also required oral nasal suctioning to manage excessive secretions and prevent her choking on, and aspirating, her own saliva. Child HR required around the clock care. Child HR was registered with the Disability Services Commission from 13 June 2013 with a diagnosis of Cerebral Palsy Spastic Quadriplegia, and she transferred on 30 June 2015 to a National Disability Insurance Agency (NDIA) plan. A carer service known as ‘At Home Care’ provided carers, day and night, through the plan.
Child HR suffered from recurrent chest infections and aspiration pneumonia. Her chest was further compromised by scoliosis (curvature of the spine). She was prescribed prophylactic antibiotics in an effort to reduce the frequency of her chest infections. She also experienced recurrent seizures, despite medications, and suffered episodes of heart block, especially during sleep. She was prescribed a large number of medications to manage all her health conditions.
There were issues reported in relation to Child HR and her parents from 2011.
Communities first became involved on 28 December 2011 when Child HR was one year old, following a Family Domestic Violence Incident reported to police by HC.
No intervention action was taken at the time by Communities.9
Child HR’s father left the marriage when Child HR was four years old. The marriage breakdown was apparently acrimonious, with Child HR’s parents disagreeing as to the appropriate living arrangements for Child HR. After the divorce, HC was largely sole parenting her daughter in these early years and she lived with Child HR in a rental property in Caversham. A team of carers assisted HC to provide Child HR with 24 hour care. HC also worked casually outside the home in a cleaning business owned by her mother.10
Child HR was described as a beautiful young girl with a contagious smile. She loved cuddles and interacting with the special people in her life. She enjoyed playing with her toys, spending time outdoors and listening to music. Child HR was said to have had a particularly strong relationship and connection with her mother, HC. Her mother was her primary care giver throughout her life and her mother understood Child HR’s care needs and behaviours. Doctors had observed there was a secure attachment between mother and daughter, with Child HR visibly calming to the voice and touch of her mother, and her teachers noted she indicated the word ‘love’ when her mother’s name was mentioned.
8 Exhibit 2, Tab 8 and Tab 21.
9 Exhibit 2, Tab 9.1.
10 Exhibit 1, Tab 13; Exhibit 2, Tab 8.
She had three rooms dedicated to her care and enrichment and all of the evidence points to a loving and nurturing home environment.
There were some concerns raised by Princess Margaret Hospital (PMH) staff in 2012 about some unaccounted use of Child HR’s disability funding, but it is still very clear from the evidence that Child HR was well cared for and nurtured. It was observed by people involved in her care that Child HR’s environment had many of the extra little things that demonstrated love and care for the little girl, including nice toiletries, hair accessories, nail polishes, lovely clothes and thoughtful room decorations. These were all things that were arranged by her mother to ensure that Child HR’s home environment was not just safe but also nurturing and joyful. She was always well presented, with hair done nicely, teeth brushed and in clothes that fitted well.11
Even towards the end, when significant concerns were being raised about how HC was functioning on a personal level, people who attended the home were impressed by how pristine and well ordered the home environment was, and it was clear to them Child HR was very well looked after in terms of her general environment.12
From the perspective of Child HR’s grandparents, they saw that their daughter had some personal issues, but they believe her personal circumstances “never affected her extraordinary care for [Child HR] whom she managed entirely on her own” after Child HR’s father left. They were witness to how HC’s life was dedicated to her daughter’s wellbeing, which took its toll upon her, particularly when Child HR’s father re-entered her life after many years absent.13
Child HR attended Durham Road Education Support School five days a week. She had been attending the school since February 2013 when she enrolled in Kindergarten. Her school notes indicate that Child HR attended school regularly and always arrived on time and in immaculately clean condition, with everything she needed for her school day. Child HR was happy to come to school and was learning to use a communication device by tapping a button with her head. She would talk about how much she loved her room at home and her fish, and it was also apparent to the staff that Child HR loved her mother very much. HC engaged well with Child HR’s teachers and was always polite and courteous to staff. Although the school generally had no concerns over HC’s dedication to the wellbeing of her daughter, staff had previously raised some concerns over HC’s management of Child HR’s medications and the possibility HC was sometimes presenting as affected by substances. 14 11 Exhibit 1, Tab 11.3
13 Exhibit 1, Tab 11.1.
14 Exhibit 2, Tab 29.
Whilst acknowledging that HC loved her daughter very much and devoted herself to caring for her after the tragic incident that led to her severe medical issues, it is also important to acknowledge that HC had a long history of misusing prescription medications. The incident when Child HR suffered a hypoxic brain injury was suspected to have occurred while HC was affected by prescription medications, and in the years afterwards, concerns were repeatedly raised by various external sources that HC was continuing to abuse prescription medications, negatively affecting her ability to safely care for Child HR. I have set out some of the occasions below when such concerns were raised with Communities. The chronology demonstrates Communities took steps each time to try to support HC to address her substance use, as it was clear when she was sober and substance free, she was a loving mother who posed no risk to her daughter.15
HC attended a Medical Centre in Midland for routine GP care for many years, seeking treatment for various complaints including sinus congestion, musculoskeletal pain, both acute and chronic, and psychosocial stress in the context of caring for Child HR and custody battles with Child HR’s father. Her medical records show she had a known severe and chronic benzodiazepine dependence, which had been identified as early as 2005. She was known to ‘doctor shop’ to get extra prescriptions. In 2012, HC was convicted of forgery in relation to altering a prescription for benzodiazepines to double the amount dispensed. Reading through her GP notes, there is an ongoing pattern of drug seeking behaviour and in August 2021, opiate dependence and pseudoephedrine dependence were added to HC’s health problems list in her GP records by her GP.16
The first time Communities was notified of such a concern was on 11 January 2012, when Communities received a referral from Fremantle Hospital. HC had been pulled over by police driving with Child HR in the car. She had appeared drowsy so she was taken by police to hospital, where she tested positive for amphetamines and benzodiazepines. When leaving hospital, HC fell over with Child HR in her arms and the back of Child HR’s head hit the pavement. Child HR was taken to PMH and admitted for observation, although she ultimately suffered no serious injury. The specialist, hospital based Child Protection Unit (CPU) were notified and conducted an interview with HC. Although her demeanour raised concerns of substance use, it was accepted that her behaviour might also be attributable to a severe anxiety disorder. It was decided that Communities should be notified, particularly given the concerns about her driving.17
Communities completed an intake for Child HR, which progressed to a Safety and Wellbeing Assessment. HC submitted to testing, which suggested the initial result for amphetamine was a false positive. The benzodiazepines were prescribed to her for panic and anxiety attacks. She reported she had taken one more tablet than the prescribed dose that day along with ibuprofen for back pain. HC told Communities she intended to seek an alternative medication to benzodiazepine for her anxiety and 15 Exhibit 2, Tab 8.
16 Exhibit 1, Tab 2 and Tab 20, Tab 23.
17 Exhibit 2, Tab 9.1 and Tab 21.3.
[2025] WACOR 19 advised she was working closely with her new doctor on managing her mental health issues. Communities felt the concerns had been addressed, so the case was closed in February 2012.18
On 12 November 2012, PMH staff became concerned HC’s substance use (illicit and prescription) might be ongoing and could possibly include her misusing her daughter’s medications. Enquiries established HC had twice approached PMH staff and requested benzodiazepines, had appeared drug affected during her daughter’s outpatient appointments, leading to Child HR’s surgery being postponed until HC was able to demonstrate she could manage Child HR’s postoperative care, and a number of concerns about how Child HR was supervised, as well as concerns about how HC was using Child HR’s funding. This led to reports to the PMH CPU and a referral from them to Communities. Communities progressed the concerns to a Child Safety Investigation, and as part of the investigation HC advised she was seeking support from Royal Perth Hospital regarding her prescription medication use. The investigation established harm for neglect, but Communities determined the safety issues had been addressed and the case was closed on 27 May 2013.19
A number of family violence incidents were also reported, involving HC as the victim and various alleged perpetrators, including Child HR’s father, another family member and HC’s other partners. HC sought Violence Restraining Orders on occasion, which were granted, and as a result, Communities generally did not take action.20
Concerns were raised by St John of God Hospital Midland (SJOG) in September 2016 regarding emotional abuse and neglect when Child HR was 6 years old. She had been brought to hospital by ambulance unaccompanied. HC arrived a little while later and appeared under the influence, although she denied drug use. She was admitted as a social admission due to HC’s presentation. Communities staff met with HC the next day and she presented as drowsy, had difficulty keeping her eyes open and slurred her words. She denied using prescription medication and maintained she was just fatigued after caring for her daughter. However, she declined to complete urinalysis testing. HC reported that she was prescribed Tramadol for pain but didn’t take it. She was taking benzodiazepines when feeling anxious and her GP had completed a Mental Health Care Plan and referred her to a psychologist.21
Communities obtained a list of HC’s Pharmaceutical Benefits Scheme (PBS) claims history, which showed between January 2015 and August 2016 she had been prescribed a very large amount of the benzodiazepine diazepam, tramadol, and for six months escitalopram, along with sporadic amounts of other medications. Her GP was contacted and the GP discussed referring HC to a detoxification facility.22
Further concerns were raised after enquiries established that a man who had attended the Communities meeting with HC, and who had been introduced as Child HR’s 18 Exhibit 2, Tab 9.1.
19 Exhibit 2, Tab 9.1.
20 Exhibit 2, Tab 8.
21 Exhibit 2, Tab 9.1.
22 Exhibit 2, Tab 9.1.
[2025] WACOR 19 carer, was being paid from HC’s NDIS funding but was alleged to be in a romantic relationship with HC. Another meeting was held on 14 September 2016 with HC and the carer, to clarify the situation, before a Signs of Safety Mapping meeting was held on 19 September 2016 with HC, her parents and SJOG hospital staff. During the meeting, HC agreed to discuss detoxification options with her GP and it was agreed Communities would explore some options for more in home support and respite options for Child HR.23
Steps were taken to reduce HC’s benzodiazepine use, her partner was removed from the paid role as HC’s respite worker and a recommendation was made that Child HR’s NDIS funding be managed by a service provider instead of her mother. The investigation established Child HR was at risk of further harm, so Communities referred the family to the Intensive Family Support Team in October 2016. During the period of intensive family support, Child HR’s father’s concerns over HC’s use of prescription medication heightened and led to him taking some actions over the parenting arrangements of Child HR.
HC engaged with a psychologist during this time and began reducing her prescription medication use, with steps taken for her to collect it each day from a pharmacy after she admitted to her GP that she was taking a whole day’s prescription of benzodiazepines at one time. There were still concerns raised about HC appearing under the influence in April and May 2017, but her use of benzodiazepines continued to be closely managed and by 1 November 2017, Communities closed the case. Over this time, the Centre for Cerebral Palsy increased their funding for in-home respite care for Child HR, which also addressed some of the concerns.24
HC engaged with Holyoake for help with codeine dependence around this time and was place on Suboxone therapy, which she completed in July 2018. HC’s regular GP also stopped prescribing benzodiazepines to her in 2018. HC had known opiate dependence and pseudoephedrine abuse, but she was still prescribed these medications by her GP from time to time, when it was considered medically appropriate. Her use of substances seemed to fluctuate, but seemed reasonably well managed until the middle of May 2019, when concerns began to be raised again.25
PCH staff, staff from Child HR’s school and another service provider all raised concerns in May and June 2019 that HC was presenting with slurred speech and appeared to be driving under the influence with Child HR in the car. On one occasion, a PCH staff member had to take HC’s car keys to prevent her from driving as it was deemed unsafe. HC provided a number of explanations for her behaviour, including having some falls and sustaining injuries to her foot and head.26
Concerns were also raised that HC was using her daughter’s clonazepam medication and PCH staff had been notified that HC had filled a large number of prescriptions for the benzodiazepine diazepam. HC’s PBS summary showed this was correct, with HC receiving large quantities of diazepam from 1 December 2018 to May 2019. This 23 Exhibit 2, Tab 9.1.
24 Exhibit 1, Tab 2 – 3; Exhibit 2, Tab 8.
25 Exhibit 1, Tab 2 – 3 and Tab 23.
26 Exhibit 2, Tab 8.
[2025] WACOR 19 was despite the fact her regular GP was not currently prescribing her benzodiazepines. PCH advised HC had been asking them repeatedly for prescriptions for benzodiazepines for Child HR.27
Child HR’s General Paediatrician had referred Child HR’s case to the CPU on 9 May 2019 for the concerns in relation to HC’s possible abuse of benzodiazepines and repeated drug-seeking behaviour. She had clarified that she had no concerns for Child HR’s physical wellbeing, as she was cared for extremely well, but she was concerned about Child HR’s emotional wellbeing due to her mother regularly appearing under the influence.28 Child HR’s General Paediatrician explained at the inquest that Child HR did not require high level medical care all the time, but she did require “a competent adult to be in the house with her at all times and be able to respond to emergencies at all times.”29 If HC was under the influence, she could not fill that role as a competent adult. There were also concerns that some of Child HR’s medications, particularly her benzodiazepines, were potentially being diverted to be used by her mother. Although Child HR’s General Paediatrician had also witnessed HC to be a caring and involved mother, the concerns raised were not a one-off concern and Child HR’s General Paediatrician explained she had a duty of care to Child HR, as her patient, to raise any concerns that might impact upon her safety.30 Having passed the concerns to PCH’s CPU, those concerns were then communicated to Communities.
In July 2019, Communities obtained a copy of Child HR’s PBS statement and PCH pharmacy records, which showed significant discrepancies with the amounts of medication Child HR had been dispensed, when compared to her medication regime, including her clonazepam medication. As a result, her clonazepam medication was changed to be dispensed only once per week from a specified pharmacy.31 Child HR’s General Paediatrician also gave evidence she gave a direction that all prescriptions for Child HR generated within the hospital would be done by her, to limit the possibility of additional prescriptions being given, and the prescriptions were sent directly to the pharmacy for dispensing. However, this did not restrict her GP from prescribing additional medications, which could then be dispensed at other pharmacies.32
Around this time, HC reported that she had been involved in a car accident and her car was a write off. Child HR and her respite carer were also in the car at the time of the car crash.33
It was recorded at this time that Child HR was under paediatric palliative care and PCH provided Communities with Child HR’s Emergency Care Plan, dated 10 January 2019, that reflected a recent and ongoing deterioration in Child HR’s health.
27 Exhibit 2, Tab 8 and Tab 21.6.
28 Exhibit 2, Tab 21.7.
31 Exhibit 2, Tab 8.
33 Exhibit 2, Tab 8.
[2025] WACOR 19 The Care Plan noted, amongst other things, that resuscitation should not be attempted in the event of cardiopulmonary arrest.34
HC was informed that Communities’ Child Safety Investigation had found that Child HR was likely to be harmed as a result of neglect and the case was once again referred to the Intensive Family Support Team. HC asked for a review of the Child Safety Investigation conclusion, which was completed in August 2019 and confirmed the decision. An interim safety plan was put in place for Child HR, which included that HC was not to be under the influence of substances when transporting Child HR in the car or when providing for Child HR’s basic care needs. HC signed an agreement for urinalysis testing. She completed the urinalysis between October and November 2019, all of which were clean.35
However, in December 2019 concerns were raised again by doctors that she was presenting as under the influence, as well as having injuries not consistent with her explanation of a fall. On 31 December 2019, Communities’ staff conducted a home visit and found HC appeared to be under the influence and covered in bruises. They implemented the safety plan, whereby Child HR was not able to be left alone with
HC’s mother advised that neither she, nor her husband, had the capacity to support HC in her care of their granddaughter.37
HC continued to present as intoxicated over the following days, so Communities held a Multidisciplinary Case Consultation and agreed that 24/7 care would be provided for Child HR via NDIS until her mother presented as sober and it was confirmed by urinalysis.38
On 10 January 2020, HC’s mother contacted Communities staff and asked them to ‘back off’ as HC was depressed and her family were concerned that she would take her own life. HC’s mother expressed her belief that HC’s mental health was declining due to Communities staff hounding her. Communities staff visited HC at home on 15 January 2020, and her mother and father were there to support her. HC’s parents accepted that HC had some issues with substance misuse and they indicated they had arranged for her to commence counselling. HC also agreed to commence urinalysis.39 34 Exhibit 2, Tab 9.1.
35 Exhibit 2, Tab 8.
36 Exhibit 2, Tab 9.1.
37 Exhibit 2, Tab 9.1, p. 14.
38 Exhibit 2, Tab 9.1.
39 Exhibit 2, Tab 9.1.
HC’s parents continued to be involved with their daughter and Communities over the following weeks. HC’s mother felt her daughter’s slurred speech might be attributable to facial fractures she had sustained, and she was very concerned for her daughter’s ongoing mental health due to the monitoring by Communities.40
HC began seeing a psychologist on 3 February 2020. The psychologist noted that HC scored in the extremely severe range for depression, anxiety and stress symptoms and her initial formulation was that HC was living with complex grief and possibly Post Traumatic Stress Disorder. She exhibited perfectionist traits and expressed feelings of inadequacy because she could not look after Child HR on her own and her adult son was not living with her. She seemed willing to engage in counselling and was open to new techniques to set boundaries and begin to process her trauma.41
Child HR had a hospital admission in early March 2020 due to respiratory issues and was diagnosed with pneumonia. Although understandably distressed at her daughter’s decline in health, HC also appeared to be drug affected when attending PCH. Staff raised concerns with a Senior Social Worker on 7 March 2020 about HC’s possible drug use and her aggression when it was suggested she go home until sober. The Social Worker went to the ward and met with HC’s mother, who had come to the hospital to try to take HC home. HC was in a deep sleep at this time and her mother suggested she might become aggressive if woken, so it was better to let her sleep it off. The Social Worker discussed HC’s substance use with HC’s mother, who indicated she believes HC was using Child HR’s medication, but HC denied it when questioned.42
The next day, the Social Worker spoke to HC, who appeared either intoxicated or drug affected, bumping into walls and equipment and slurring her speech. HC denied drug or alcohol use but said she was exhausted. HC discussed a difficult meeting she had recently had with medical staff about palliative care for Child HR, which she had found confronting and overwhelming. Her son was also going through some significant issues and her partner had been deported from the country. She reported previous suicidal ideation but denied any acute thoughts of self harm. The Social Worker tried to convince HC to go to Sir Charles Gairdner Hospital for medical assessment, but she declined and got in a rideshare taxi to go to a friend’s house. The Social Worker rang and spoke to HC’s mother, who advised that she and her husband were feeling overwhelmed by HC’s obvious issues and didn’t know what to do. She had confronted her daughter about using Child HR’s medications, but she continued to deny it. It was agreed at that stage that the safest place for Child HR was in hospital.43
HC continued to present to PCH in a drug affected state, and she was eventually taken to hospital herself on 11 March 2020 after being found on the floor. She had an episode of being incoherent while in hospital before being discharged.44 40 Exhibit 2, Tab 9.1.
41 Exhibit 1, Tab 25.
42 Exhibit 2, Tab 21.9.
43 Exhibit 2, Tab 21.9.
44 Exhibit 2, Tab 9.1.
On 13 March 2020, Communities staff attended a meeting at PCH regarding HC’s presentation during Child HR’s admission. PCH reported that HC had presented as drug affected nearly every day, often being incoherent and unable to talk or walk small distances. On one occasion she soiled herself as she was unable to walk. PCH staff had been unable to speak with HC about Child HR’s condition or end of life plan due to HC’s intoxicated state. However, HC continued to deny drug use.45
Child HR was discharged home on 18 March 2020, with the safety plan still in place so a support worker remained with her overnight. Over the following days, HC continued to present with slurred speech and concerns were raised that her mental health was deteriorating. However, the support worker who was staying each night provided a different viewpoint, and they indicated they had not seen HC drink or take alcohol and they believed she did not require overnight support to care for Child HR.
Nevertheless, overnight support continued to be provided as part of the safety plan.46
HC disclosed to a SJOG Psychiatric Liaison Nurse that she had also used her daughter’s Phenobarbitone medication, although she later retracted this statement.
HC also admitted she had been giving Child HR oxygen contrary to her neurologist’s recommendation. HC was diagnosed with alcohol intoxication, although toxicology analysis also showed phenobarbitone at levels indicating regular excessive use of the medication. Her liver function test also suggested a long history of problem drinking.
HC was discharged home the same day.47
HC had been offered an appointment around this time with Holyoake for help with her increase in alcohol use, but she then cancelled the appointment and did not reschedule.48
The information about her hospital admission escalated Communities’ concerns and it was determined on 7 April 2020 that Child HR was in need of protection. HC was advised on 20 April 2020 that Communities would be applying to the Children’s Court for a protection order for Child HR, but she would remain placed with her mother at home, with 24/7 support provided. HC reportedly responded by stating “that she had no reason to be alive.”49
Communities applied to the Children’s Court for a protection order for Child HR, and an interim order was granted by a Magistrate on 24 April 2020. Although the order was granted, a plan was agreed that Child HR would return home to live with her mother, but that At Home Care would provide care overnight and other care workers would attend the home to assist during the day. This meant that Child HR and her mother were not separated, but there was extra supervision as well as 45 Exhibit 2, Tab 9.1.
46 Exhibit 2, Tab 9.1.
47 Exhibit 2, Tab 9.1.
48 Exhibit 2, Tab 9.1.
49 Exhibit 2, Tab 9.1, p. 17.
[2025] WACOR 19 support, funded by her NDIS plan. At Home Care commenced caring for Child HR overnight on 13 May 2020.50
It appears HC had another car accident in May 2020. Her GP advised Communities she had been prescribed Panadeine Forte and tramadol for pain relief.51
Just over a week after At Home Care commenced overnight support, Communities received a referral from the support service regarding neglect concerns for Child HR.
It was reported that At Home Care staff had called SJA after HC had sustained a head wound after falling of a chair while intoxicated. She was taken to SJOG and was admitted to the Short Stay Unit overnight for observation before being discharged. Her primary diagnosis was intoxication, with her blood alcohol level on presentation recording as 0.290%. After this incident, Communities met with HC and it was agreed she would resume counselling with her psychologist, not drink to excess in the home and complete urinalysis three times per week. She also signed a consent for release of information from her GP Medical Centre regarding her prescription medication for the previous 12 months. HC commenced regular urinalysis at this time.52
The first urinalysis result was positive for benzodiazepines and barbiturates. HC was told she was not to drive with Child HR in the car after this result and on 6 June 2020 discussions began within the Communities’ team about what supports Child HR would require if she was moved from her mother’s care. On 8 June 2020, Communities began seeking a Disability Support Placement for Child HR, and then a Needs Assessment Report was completed, continuing with the possible plan to remove Child HR from her home and place her elsewhere.53
On 25 June 2020, Child HR’s school raised concerns that Child HR’s sealed medication had been tampered with and that some of her clonazepam medication had been removed and replaced with an unknown medication (later found to be melatonin). The bottle should have contained 100 clonazepam tablets, but 30 were missing, replaced with the melatonin. It was suspected that HC had tampered with the medication. HC initially suggested it may have been the At Home Care support worker.54 Communities staff undertook a Signs of Safety meeting with HC and an agreement was reached that Child HR’s medications would be stored in a locked box and only accessed by the registered nurse caring for Child HR, and no spare medications would be left in the home. The pharmacist who dispensed Child HR’s medications was also advised not to dispense Child HR’s medication to her mother.
Further, it was arranged that an At Home Care worker would be contracted to provide Child HR’s care before and after school, as well as overnight care.55
51 Exhibit 2, Tab 9.1.
52 Exhibit 2, Tab 9.1.
53 Exhibit 2, Tab 9.1.
54 Exhibit 1, Tab 2 and Tab 25.
55 Exhibit 2, Tab 9.1.
[2025] WACOR 19 previously misused benzodiazepines and alcohol, which had led to some falls and associated injuries. However, she denied she would do anything that would put her daughter at risk.56
Communities had been exploring alternative placement options for Child HR for some time by this stage, and those options continued to be explored in the following months.57
HC was seeing her psychologist from July to November 2020 and was reported to be engaging well. The sessions continued into the new year, until she stopped turning up to psychological appointments after March 2021.58
Throughout this time, Communities continued to obtain special purpose funding for At Home Care to provide supervision and support for Child HR while living at home with her mother. Different support coordination services were brought into assist with managing Child HR’s various supervision and medical needs.59
HC had been providing clear urinalysis tests since June 2020 and on 29 March 2021, a meeting was held with HC and it was agreed instead of the original 2 year protection order, Communities would apply only for a 6 month protection order. On 5 May 2021, a Magistrate in the Perth Children’s Court made a Protection Order (Supervision) in relation to Child HR for a period of six months.60
The six month protection order expired on 5 November 2021. By that time, after intensive involvement with urinalysis and counselling, Communities was satisfied that HC had maintained sobriety since June 2020 and demonstrated overall improvement in mental health. They believed the safety concerns had resolved, so Communities closed its case on 19 November 2021.61
57 Exhibit 2, Tab 9.1.
58 Exhibit 1, Tab 2 and Tab 25; Exhibit 2, Tab 9.
59 Exhibit 2, Tab 9.1.
60 Exhibit 2, Tab 8 and Tab 9.
61 Exhibit 2, Tab 8.
[2025] WACOR 19 care for Child HR due to a relapse into alcohol abuse and misuse of prescription medications. In particular, it was alleged that HC was driving with Child HR when she was unfit to drive and Child HR’s medications were sometimes missing.
A report from the Nurse Manger of the support service, At Home Care, indicated that At Home Care’s most challenging aspect in relation to caring for Child HR was following Communities closing the case and Child HR returning to her mother’s care. “HC had the control to direct, change, cancel, or choose to provide direct care to Child HR,”62 which caused some issues.
A different GP at the medical practice consulted with HC in late November 2021, after HC’s pharmacy rang wanting another prescription for HC’s Sudafed (pseudoephedrine). The doctor noted her regular GP had prescribed a significant quantity with two repeats only 10 days prior, so she declined to provide another prescription. The doctor brought to her regular GP’s attention her concern that it appeared HC was abusing the pseudoephedrine medications and HC had blocked access to her health record, which raised further suspicion. Clinic staff had raised concerns about HC showing signs of possible mental impairment on her last few visits and it was suggested that consideration should be given to declining further prescriptions for pseudoephedrine and possibly notifying the Department of Transport about concerns in relation to her fitness to drive. It is not clear whether any further action was taken at this time in relation to the Department of Transport. She continued to be prescribed pseudoephedrine by her regular GP, although other GP’s at the practice raised concerns.63
The first concern was raised with Communities by PCH on 1 December 2021. HC had presented with slurred speech during telephone conversations and disclosed that she had relapsed. She had also made additional requests for clonazepam for Child HR for both home and school, but when PCH staff contacted Child HR’s school, they confirmed they had ample supply of the medication. School staff also advised Communities HC had presented as incoherent at school and had an open bottle of clonazepam in her possession. She told school staff the bottle of clonazepam had smashed and requested more from them, which they declined. No concerns were expressed for Child HR’s health, only her safety in her mother’s care. HC was contacted the following day and she agreed not to drive with Child HR in the car.
Members of HC’s safety network were also contacted and they agreed to provide her with additional support.64
64 Exhibit 2, Tab 9.1.
65 Exhibit 1, Tab 23.
On 8 December 2021, Communities staff met with HC, her mother and a friend, along with Child HR’s support coordination service provider. A safety plan was drafted for HC and her safety network.66
HC saw her regular GP on 29 December 2021, who raised concerns about HC’s significant pseudoephedrine use. HC denied supplying anyone else with the medication and appeared to suggest her pharmacist had lost the prescription, although another GP at the practice had confirmed with the pharmacist that all of her previous prescriptions had been filled. HC agreed to be careful with the medication.67
Ms Danielle Miller, who was the Client Engagement Manager for At Home Care at the time, visited HC’s home in January 2022 with a registered nurse from the service, as they had been hearing concerning reports about issues in the home and there were some issues with the NDIS funding that required clarification.68 Ms Miller gave evidence the home was pristine and well organised and HC was very receptive to them and informative about Child HR’s needs. Ms Miller recalled that at the time she felt confused by the person she had met and reports they had been receiving, although she noted the concerns were generally related to HC being intoxicated in the home and misusing medications.69 It is consistent with the general feedback that HC was a wonderful mother when she was not affected by alcohol or substances, and it was only when using substances that concerns arose.
In late January and early February 2022, HC saw her doctor with two injuries to her right foot and requested analgesia. When she returned to see her regular GP, on 9 February 2022, HC was struggling to cope, emotional and tearful, although she denied any suicidal thoughts. She reported speech and swallowing difficulties and admitted to drinking more alcohol amidst ongoing issues with her ex-husband, who was threatening to get custody of Child HR and take her to Queensland, as well as conflict with her mother and son. During the consultation, her doctor addressed the issue of HC obtaining a prescription for Child HR for clonazepam (a benzodiazepine) from an after-hours service. The medical notes implied HC could be suspected of taking this herself, noting her known benzodiazepine dependence. HC denied this suggestion. Her doctor indicated she did not think extra medications were a good way to deal with her distress and suggested weekly reviews so she could provide counselling were appropriate from that time.70
The following day, HC called the medical centre and spoke to a different GP. Her speech was slurred during the call and she asked for a copy of the consultation notes from the appointment the day before. She claimed they were required for Child HR’s support agency. With her regular GP’s permission, they were provided.71 66 Exhibit 2, Tab 9.1.
67 Exhibit 1, Tab 23.
70 Exhibit 1, Tab 2 and Tab 23.
71 Exhibit 1, Tab 23.
Funding issues arose in early February 2022, after Child HR’s support coordinator advised At Home Care that funding was only likely to last three weeks. This raised concerns about how support could continue to be provided in the home, at a time when there were significant concerns about HC’s ability to cope.72
On 10 February 2022, Communities received a referral from Perth Support Coordination Services detailing neglect concerns for Child HR. It was reported that HC had been consuming “enormous amounts of alcohol”73 since Communities had closed the case and it was felt this might be impacting on her mental health and compromise her care of Child HR. Further, support workers had been calling in sick as they did not wish to attend HC’s house. An At Home Care support worker had also reported that they could not leave their shift on 6 February 2022 as HC was too intoxicated to care for Child HR, and may have also been taking sleeping pills.74
Early in the morning on 11 February 2022, at 2.14 am, police received a call from a person who was reporting concerns for HC’s welfare. HC had knocked on the callers door, holding her abdomen and leg, and apparently under the influence. She claimed she had been assaulted by strangers who had then stolen her wallet and phone. Police attended and spoke with HC, who gave changing accounts of the alleged assault. She did have apparent minor injuries, so SJA attended, but HC declined treatment. HC was taken home by police and one of Child HR’s support workers told the police HC’s phone and wallet were inside and HC had been involved in an argument with her boyfriend before HC had kicked him out of the house. The police officers left HC at her home and did not investigate the matter further.75
Several hours later, at 11.00 am, on the same morning, HC attended the Kiara Police Station in a distressed state with obvious bruising to her left eye, arms and legs. She was intoxicated and seemed barely capable of speech. It was eventually established that HC had allegedly been assaulted by her boyfriend. An Incident Report was created but enquiries established the boyfriend was a FIFO worker and he had returned to work. An ambulance was called to the police station and HC was taken by ambulance to hospital. The police investigation did not proceed further.76
On examination at the hospital, HC had multiple bruises and abrasions noted to her back, limbs and left eye. She appeared intoxicated and was a poor historian. A urine drug screen was positive for methamphetamine and benzodiazepine and her blood alcohol level was 0.13%. She was given opiates for pain and after imaging detected no abnormalities, she was medically cleared for discharge. Before leaving hospital, she had a social work review, which noted that there was an open case with Child HR. The social worker obtained information from the manager of At Home Care, which established Child HR’s carers had expressed concerns over HC’s daily alcohol use, erratic behaviour, suspected drug use and verbally aggressive behaviour. It was 72 Exhibit 2, Tab 19.
73 Exhibit 2, Tab 9.1, p. 28.
74 Exhibit 2, Tab 9.1.
75 Exhibit 1, Tab 2.
76 Exhibit 1, Tab 2.
[2025] WACOR 19 reported that carers had declined to finish their shifts due to concerns for Child HR’s welfare.77
Communities commenced a Child Safety Investigation on 11 February 2022, based on the concerns being raised by external sources. The support workers, HC’s GP and health professionals who had involvement with Child HR were all expressing concern about HC’s mental state and substance use and indicating they did not have trust in her judgment anymore. It was noted that HC refused to seek mental health support and although she took various mental health medications, she had not formally been diagnosed with any specific mental health condition. It was also noted that Communities staff had told HC last time that if Child HR came back through intake again, she was likely to lose care of HC, but she had immediately relapsed into substance use once the case was closed. Although there were no specific concerns being raised about direct harm being caused to Child HR, the fact that Communities continued to receive reports that HC was significantly intoxicated and in an unfit state to care for Child HR and her high needs was a significant concern and it was felt placed HR at immediate risk of harm. Therefore, Communities determined neglect had been substantiated at that stage.78
Communities staff contacted At Home Care on 14 February 2022 and were advised that a number of support workers had raised concerns about HC presenting as intoxicated and being unfit to care for Child HR when on her own for two to three hours between evening shift changes. Further, HC had instructed support workers to attend the pharmacy to purchase pseudoephedrine for her, as customers were required to present a driver’s licence to purchase the medication. The support workers had been advised not to do so. Further, support workers were having to assist HC to administer Child HR’s medication when she was not in a fit state. In addition, they reported HC was often falling over when intoxicated, resulting in scratches and bruises.79
On 15 February 2022, HC reported to her GP she had been assaulted by her new partner a few days before, consistent with the account of this incident. The GP’s notes indicate she advised HC to stay off all stimulants, including pseudoephedrine, and limit drugs of dependence. She denied HC’s request for a benzodiazepine prescription. HC was not referred to drug and alcohol services as she did not acknowledge she had an issue, but she was counselled on the impact being under the influence of drugs would have on her ability to care for her daughter, and counselled on making sure she was not responsible for Child HR’s care when affected by drugs and not to drive when affected. HC appeared to suggest to her doctor that she had not deliberately ingested the methamphetamine.80
A Communities Senior Child Protection Worker, Megan Riising, had a long phone call with HC on 17 February 2022, during which they discussed the incident between herself and her partner and her alleged drug use, including testing positive for benzodiazepines. She claimed her partner must have spiked her drink. When she was 77 Exhibit 1, Tab 2 and Tab 24.
78 Exhibit 2, Tab 8 and Tab 11.
79 T 39; Exhibit 2, Tab 9.1 and Tab 29.4.
80 Exhibit 1, Tab 2 and Tab 23.
[2025] WACOR 19 challenged about her history of benzodiazepine dependence, she became upset. She was then told that Communities had opened a child safety investigation, and she became even more upset and agitated. HC denied drug use and said she was happy to do drug tests to prove it.81
Child HR’s father and mother continued to have conflict over parenting arrangements. On 21 February 2022, Child HR’s father contacted Communities to raise concerns about reports he had heard about HC’s physical state.82
Senior Child Protection Worker Natasha Babac had taken over as Child HR’s case manager on 18 February 2022. Ms Babac called HC on 25 February 2022 in an attempt to discuss Communities’ worries but HC did not wish to engage with her and deflected the concerns being raised. After the call, Ms Babac texted HC and requested she complete urinalysis.83 HC was undertaking urine drug testing regularly at that stage, with most of the results showing pseudoephedrine, consistent with the medication she was prescribed.84
On 28 February 2022, Ms Miller from At Home Care advised Ms Babac that the 24/7 support workers that were in place for Child HR would no longer be available, due to funding being cut and there being no support workers available to cover the shifts.
Ms Babac clarified with Ms Miller that the funding issue would likely be able to be resolved, but the issue of finding support workers would still remain. Ms Babac gave evidence this conversation raised significant concerns for Communities, although the child safety investigation was still in the early stages.85
On 1 March 2022, Communities staff held a meeting with HC to give her an opportunity to respond to the reported concerns. She denied misusing drugs but did admit she had not been in the best mental space following the incident on 11 February 2022. She acknowledged she had a problem with alcohol and said she was seeking help with her addiction, but she was dismissive of the concerns being raised and didn’t see a reason why Communities needed to be involved. Communities staff reiterated she could not consume alcohol or use unprescribed medication while having the sole care of her daughter and they requested that HC advise of her support network. Ms Babac explained that it was difficult to conduct safety planning with HC because of her unwillingness to engage and discuss their concerns.86
On 7 March 2022, Child HR was admitted to PCH due to her ongoing seizures.
Communities staff were advised the following day that the seizures were due to changes in her medication, which was then reviewed. Her support worker stayed in the hospital with her overnight and she was discharged home the following day.87 81 Exhibit 2, Tab 29.5.
82 Exhibit 2, Tab 9.1.
83 Exhibit 2, Tab 10.2.
84 Exhibit 2, Tab 9.1.
85 T 89; Exhibit 2, Tab 10.1 and Tab 29.9.
86 T 91 - 92; Exhibit 2, Tab 9.1, Tab 10.2 and Tab 29 87 Exhibit 2, Tab 10.2.
On 8 March 2022, Child HR’s father sent an email raising concerns about HC driving with Child HR in the car due to HC’s alcohol and substance abuse.88
On 9 March 2022, Communities held a Multidisciplinary Case Consultation and it was decided that intervention action was required and a protection order would be sought, with a plan to reunify Child HR with her father, who had indicated a willingness to care for her with his partner.89
On 11 March 2022, a Children’s Court Magistrate granted a warrant to bring Child HR into the provisional protection and care of the CEO pursuant to s 35 of the Children and Community Services Act 2004. Child HR’s father was advised a few days later that the warrant had been granted and the plan was for Child HR to be admitted to PCH for a short period prior to transitioning into his care, should he so wish. The admission to PCH would allow him time to set up Child HR’s room and medical equipment, and he would then have the ongoing support from At Home Care. He agreed with the plan.90
On 14 March 2022, Communities rang PCH and advised of the plan, but PCH advised that an interim social admission was not possible due to the risk of Child HR contracting COVID-19. PCH staff also advised they had reservations about Child HR being placed with her father, given his history of use of family and domestic violence against HC. Accordingly, the warrant was not enacted.91
On 16 March 2022, HC requested a letter of support from her doctor to NDIS as she understood they were proposing cutting Child HR’s weekend support to six hours and she did not feel she would cope.92
Child HR’s father notified Communities on 18 March 2022 that he was ready for Child HR to be transitioned into his care and he later agreed for At Home Care to complete a Workplace Risk Assessment at his home.93
On 27 March 2022, HC was taken to hospital by ambulance after a respite carer for Child HR had called emergency services for help. They had advised HC was becoming drowsy and had a haematoma at the back of her head. She was believed to have fallen in the shower, but reported to have no memory of the fall. On review by doctors, HC was teary, nauseous and in pain. She reported stress related to the ongoing parenting arrangement dispute and because Child HR was receiving palliative care. HC was given opioids for the pain and a CT of her head and spine was ordered, but she discharged herself against medical advice before the scans could be performed.94 88 Exhibit 2, Tab 9.1.
89 Exhibit 2, Tab 9.1.
90 Exhibit 2, Tab 9.1.
91 T 98; Exhibit 2, Tab 9.1.
92 Exhibit 1, Tab 23.
93 Exhibit 2, Tab 9.1.
94 Exhibit 1, Tab 2.
On 28 March 2022, HC did not attend urinalysis, and from that time she only attended one of the further five scheduled tests. The one test she did attend on 4 April 2022 showed clonazepam, which she was not prescribed. HC told Communities she did not attend some of the appointments as she was in York for work and because she was sick. She did, however, indicate she had provided a clean test for another matter, but Communities was unable to confirm this was correct.95
Child HR was being weaned off clonazepam at this stage and transitioned to a new medication gabapentin. HC took her daughter in to see a GP on 11 April 2022 and requested for two of Child HR’s medications, including clonazepam, to be changed from liquid to tablet form for her Webster-pak. HC claimed it was at the request of new disability carers and that the change needed to be done urgently. PCH had advised Communities on the same day that HC had requested that Child HR’s clonazepam prescription be changed from liquid to tablet form. PCH had refused the request, noting that changing to tablet form would have meant there was leftover medication that was at risk of being misused.96 Child HR’s General Paediatrician explained at the inquest that Child HR’s dose of clonazepam by that stage was very small, so tablets were too large for them to be practicable to provide that dose, and liquid was more appropriate as it can be given in very tiny doses.97
It seems, however, the change was made by the GP, not knowing of this discussion with PCH staff, although after HC’s death the GP made a retrospective note she has tried to phone the PCH pharmacy to discuss the request but they were already closed as the appointment was after 4.00 pm. The GP told HC that ongoing scripts would still need to be through PCH, particularly the clonazepam, but she had given the once off script so that HR would have safe ongoing care.98 Child HR’s General Paediatrician gave evidence at the inquest that there was no reason for Child HR to obtain alternate medications from her GP at that time, as it was all able to be done via the hospital very quickly. I am satisfied HC’s approach to her GP was, in hindsight, an example of HC’s drug seeking behaviour and she was trying to obtain the clonazepam in tablet form for her own use.99
The GP received a call from a pharmacist on 19 April 2022 discussing the change of oral syrups to tablets. She passed on the information she had received from HC and advised the tablet forms of the medications should be included in Child HR’s Webster-pak urgently.100 After being advised of HC’s death, the GP made a retrospective note in her medical records that she had received a phone call from two different pharmacies the day after changing the clonazepam to tablets, with HC wanting to fill the clonazepam scripts early and separately to Child HR’s Websterpak. The GP recorded in the retrospective note that she had advised that the tablets were only to be put in the Webster-packs, which were collected weekly. It appears HC was, in fact, dispensed the clonazepam tablets, which she then consumed prior to her death.
95 Exhibit 2, Tab 9.1.
96 T 100; Exhibit 2, Tab 15.
98 Exhibit 2, Tab 9.1 and Tab 15.
99 T 201; Exhibit 2, Tab 15.
100 Exhibit 2, Tab 15.
On 12 April 2022, Communities spoke to HC’s mother after being advised that HC was too sick to drive to urinalysis. HC’s mother confirmed HC was physically unwell, but otherwise indicated she believed HC was doing well.
On 14 April 2022, HC advised Communities she could not attend urinalysis as she had tonsillitis. That day, At Home Care provided a report to Communities regarding the incident involving HC on 28 March 2022. They advised HC had returned home from hospital and begun drinking vodka. The support worker had locked themselves and Child HR in Child HR’s bedroom due to HC’s behaviour, such as not letting the support worker out of the toilet. HC had also repeatedly asked the support work for the shift notes. Further, At Home Care advised that on the day prior to making this report, being 13 April 2022, HC had appeared drunk and possibly under the influence of other substances when she had driven herself to work. HC had asked the support worker to lie to Communities if they attended, as she did not want to complete urinalysis.101
The situation continued to deteriorate, and on 17 April 2022, At Home Care staff telephoned Communities’ Crisis Care Unit to report concerns regarding HC’s alcohol use and aggression towards the support workers. One support worker had reportedly been removed from the home and HC had said she would carry Child HR to bed. At Home Care agreed they would continue to provide a support worker 24/7, and were advised to contact police for assistance, if required.102
Two days later, on 19 April 2022, At Home Care notified Communities that the staff believed Child HR needed to be removed from HC’s care and it needed to “happen sooner than later.”103 At Home Care support staff reported incidents that had occurred during their attendance at HC’s home over the previous week, whereby HC was reported to be intoxicated to the point of falling over and not in a fit state to care for Child HR. She was playing loud music, which was disturbing for Child HR, and also being verbally abusive and aggressive to the support workers. It was noted that the At Home Care workers loved Child HR and wanted nothing but the best for her, but the workplace had become unsafe for them and they could not ensure Child HR’s safety. It was clarified at the inquest that the concerns were coming from a number of support workers and management were being drawn in to try and resolve the issues, which was taking its toll on all of the staff. The concerns outlined by At Home Care were extensive and increased the level of urgency for Communities to action.104
Communities staff determined that the likelihood of neglect was substantiated and a direction was made that Child HR would be brought into the Provisional Protection and Care of the CEO pursuant to s 37 of the relevant legislation. Unlike the previous process for a s 35 warrant, the s 37 decision indicated concern of an immediate risk of harm for Child HR, which escalated the urgency.105 PCH agreed to accept Child HR as a social admission until 28 April 2022, when it was planned that Child HR 101 Exhibit 2, Tab 9.1.
102 Exhibit 2, Tab 9.1.
103 Exhibit 2, Tab 29.36.
104 T 40 – 41, 48 - 49, 54 – 55, 58; Exhibit 2, Tab 9.1 and Tab 29.36.
[2025] WACOR 19 would transition to her father’s care. PCH also suggested Communities speak to two respite services, Harry’s House or Alkira, to determine if either of those services could provide respite care to Child HR. Alkira were contacted and indicated they had capacity but would not permit her current At Home Care support workers to care for Child HR at the centre. This presented an issue with continuity of care for Child HR.
Communities also attempted to telephone Harry’s House at this time, but did not get through. In the meantime, it was planned that Child HR would be admitted to PCH with continued support from her At Home Care support workers.106
Natasha Babac called Police Communications at 10.36 am on Tuesday, 19 April 2022 and requested police assistance at the house in Caversham as they were intending to remove Child HR from the home and they were concerned HC may be intoxicated and there were also ongoing concerns about her mental health. Ms Babac advised Child HR had complex medical needs, so SJA officers would be present to take Child HR to hospital by ambulance.107
It took some considerable time to coordinate a plan between Communities and PCH staff to make the appropriate arrangements for Child HR to be urgently admitted.108 As a result, the removal did not take place until many hours later. Eventually members of Communities’ Crisis Care Team attended the address with officers from Kiara Police Station at 7.49 pm. It is apparent from the evidence of the people involved, and body worn camera footage of the interaction, that HC was visibly affected by substances when she met the police officers and Crisis Care staff at the font door. She was described as slurring her speech and unsteady on her feet. She was also shocked and distressed at being notified of the intended removal of Child HR, and expressed concern that Child HR was settled and asleep in bed at that time of night. The timing at night is certainly unfortunate, but I note that Ms Babac had made the request many hours earlier in the morning, so it was clearly not Communities’ plan to do the removal at such a late hour.109
A question was also raised as to why there could not have been some forward notice to HC about Communities’ intention to remove Child HR that day, so she had some forewarning. Communities staff explained at the inquest they do not generally give family members prior notice that they are taking a child, due to concerns that this may place a child at risk. Although mention was made of the risk of a person absconding with their child, in this case that risk was minimal. Further, while I am sadly aware from my role as a coroner of parents taking other, more drastic, actions towards their children in times of stress and when their mental health is in decline, there is absolutely no suggestion HC would have ever deliberately harmed her daughter. However, I accept Communities need to act on the basis that people can be 106 Exhibit 2, Tab 8 and Tab 9.1 and Tab 29.
107 T 103; Exhibit 1, Tab 2 – 3; Exhibit 2, Tab 9.1.
108 T 100 – 101; Exhibit 3.1 – 3.3.
109 Exhibit 1, Tab 2 – 3 and Tab 13.
[2025] WACOR 19 unpredictable and, given the safety of the child is paramount, there is a general risk in giving prior warning in such circumstances.110
The police report indicates communication with HC was limited due to her state of intoxication, and she was overtly hostile to the police and Communities staff at times. However, she complied with the order and prepared her daughter’s things so that she could be comfortable after being removed from the premises. It’s clear that HC was worried about who would be looking after Child HR and she believed that she might be endangered by a change in caregiver. She was upset that no one would tell her where Child HR would be taken. However, she was calm and reassuring when she spoke to Child HR before she left.111
The body worn camera footage shows HC had been asked if she wanted to contact someone to attend and support her through the process, but she declined. After Child HR had been taken away by ambulance, Communities staff and police left the Caversham house at around 9.00 pm. The police documented in the CAD task that there were no issues with Child HR’s mother at the time they left. I note that she did make some comments that could have been interpreted as indicating she might selfharm, but she was calm when she made the comments and it was also possible her comments were more about the possible harm the action of removing Child HR would have on Child HR’s health. In any event, there is no evidence HC followed through with any act of self-harm that night.112
HC called her mother after her daughter had been taken and it was clear she was incredibly upset and angry with Communities about the way her case had been handled. She told her mother that she had an upcoming court date with Communities the next week, but there wasn’t much else known at that time.113
HC reportedly rang one of Child HR’s previous support workers in an intoxicated state later that night. She was frantic and threatened self-harm. The worker contacted the Mental Health Emergency Response Line and HC’s mother, before calling SJA for assistance.114
At 10.29 pm, police were called back to the house by SJA as they had received the information that HC was affected by alcohol and threatening suicide. Officers from Kiara Police Station returned to the home, arriving at 10.34 pm. Two of the officers had been involved with HC earlier in the night, and two more officers who were not involved also attended. The police officers who had not been involved in the removal of Child HR approached the house and the other two officers stayed outside, given their presence might have been upsetting for HC.115
The officers found HC was extremely distraught and it appeared that her level of intoxication had increased. She showed some outbursts of aggression, but it was due
111 Exhibit 1, Tab 2 – 3 and Tab 13.
112 Exhibit 1, Tab 2 – 3 and Tab 13.
113 Exhibit 1, Tab 10.
114 Exhibit 2, Tab 9.1, p. 36.
115 Exhibit 1, Tab 2 – 3, Tab 13 and Tab 17.
[2025] WACOR 19 to her emotional upset at her daughter being removed rather than directed at the police. The attending police officers spoke to HC and she denied being suicidal or considering self-harm. SJA officers also attended and noted a strong smell of alcohol. They observed HC’s obvious distress, but she was able to be consoled and they did not consider her to be at imminent risk of self-harm. HC’s mother was telephoned by police officers and she agreed to come and take her daughter into her care. They stayed with HC at the house for approximately 90 minutes until her mother was able to get there. HC’s mother indicated she would take her daughter home to her house. The police officers then left.116
On 20 April 2022, HC spoke to an At Home Care support worker after calling PCH and impersonating an At Home Care worker. Communities staff spoke to HC and advised her she had to seek any information about Child HR through them. She explained she had just wanted Child HR to hear her voice.118
HC came to the Communities office with her mother later that day to express her unhappiness about what had occurred. She maintained she had never returned a dirty urinalysis and requested contact with her daughter. She was told she could discuss this request with the Case Manager during a scheduled meeting the following day.
HC raised concern about Child HR being admitted to PCH where COVID-19 was present before leaving with her mother.119
HC denied misusing alcohol or other substances during the meeting. Both HC and her mother were understandably upset and the meeting seems to have been fairly tense. A priority was ensuring HC would be able to see her daughter on her birthday.
HC was told that Communities were seeking an exemption from PCH (due to the COVID rules) to allow her to visit Child HR on her birthday, but the visit would have to be supervised, at which time she became very distressed and left the meeting.
Further discussions were had with HC’s mother and it was explained that Communities would ensure HC saw her daughter the next day, even if it was a video call if PCH did not give permission for a face to face meeting.120
117 Exhibit 2, Tab 9.1.
118 Exhibit 2, Tab 9.1.
119 Exhibit 2, Tab 9.1.
120 Exhibit 2, Tab 9.1 and Tab 29.43 - 29.45.
[2025] WACOR 19 shortly after a digital copy was emailed to her. It contained information about the proceedings, as well as information about legal services and mental health support services.121
HC was upset, but still happy she would be able to see her daughter on her birthday.
HC’s mother gave her a present to give to her granddaughter and they then parted.122
HC attended the hospital at 1.00 pm for supervised face to face contact with her daughter to celebrate her birthday. She brought presents with her and was noted to be affectionate towards Child HR and spoke to her in a loving manner. At the end of the hour long visit, she was crying and hugged and kissed her daughter and told her how much she loved her.123
Towards the end of the visit, HC indicated she wanted to take Child HR’s medication home with her. When this request was refused, she became agitated and said, “oh so what you think I’m going to abuse them.”124 Communities staff confirmed that afternoon that none of Child HR’s medication was to be released to HC.
It does not seem that there was any particular discussion between HC and Communities staff after that meeting with her daughter about what would be happening next. Evidence was given at the inquest that there would have been more discussions with HC, utilising Signs of Safety meetings, to discuss the future and help her to maintain some hope and consider whether there were ways Communities could support her to have her daughter returned to her care. Unfortunately, HC died before any steps could be taken in this regard.125
Call records show that there was a call between HC and her mother at 7.31 pm that night. HC’s mother told police that when she spoke to HC, it was clear HC was angry and upset with Communities. HC’s mother knew that HC had experienced suicidal thoughts in the past and she was worried about HC’s ‘head space’ at this time as she had been constantly angry and upset since Child HR had been taken away from her. She did her best to calm HC during their conversation. HC’s mother invited HC to come to their property to celebrate Child HR’s birthday as a family, even though she was in hospital, but HC said she preferred to stay home and listen to some music. HC also asked her mother to pass on message to HC’s son, who was living with his grandparents, that she loved him. At the time, it seemed like a normal message, but in hindsight, it could indicate HC was already contemplating ending her life at that time.126 HC also sent some text messages that night to a family member 121 Exhibit 2, Tab 8, Tab 9.1 and Tab 28.49.
122 T 106; Exhibit 1, Tab 2 – 3 and Tab 10.
123 T 106; Exhibit 2, Tab 9.1 and Tab 29.48.
124 Exhibit 2, Tab 9.1, p. 37 and Tab 29.48.
125 T 143, 126 T 17; Exhibit 1, Tab 2 - 3 and Tab 10.
[2025] WACOR 19 indicating her sadness and anger at Child HR being taken from her, but did not mention anything that might have raised the alarm that she planned to harm herself.127
The following day, HC’s mother tried to call her daughter throughout the day but her phone was switched off. HC’s mother became increasingly concerned when she could not get hold of her daughter, so she drove to HC’s house at 7.00 pm to check on her. When HC didn’t answer the door, she used the spare set of keys to enter the house, where she found HC lying face down on the floor. She was cold and her mother knew she had died. She called 000 and asked for the police to attend.128
Police Communications were notified at 7.20 pm on 23 April 2022 that HC’s mother had found her, apparently deceased, on the lounge room floor. Police and ambulance officers were tasked to attend. Two police officers were first on the scene at 7.29 pm, and they were met by HC’s mother, who advised the home had been locked and secure when she arrived, and she had used her keys to enter after she had received no answer to her knock on the door. The police officers entered the house and found HC lying face down on the lounge room floor, between a couch and coffee table. She was fully clothed and her body was in a state of rigor mortis, with obvious blood poling on the front side of her body, suggesting she had been in that position for some time after death. There were no visible injuries, including no sign of a head injury. SJA officers arrived soon after and certified HC’s death. They also detected no obvious injuries and agreed it appeared HC had been lying prone (face down) at the time of, and after, death.129
The attending uniformed police officers confirmed that all other doors and windows in the house were secure, other than the front door, which had been opened by HC’s mother. The house was in a clean, orderly and well maintained state and there was no sign of a disturbance in the house. The police were advised by HC’s mother about the circumstances of the recent removal of Child HR from her mother’s care and HC’s history of prescription medication misuse and previous suicidal ideation and self-harm. The police officers searched the house for prescription medications and located Child HR’s clonazepam medication. It had been dispensed on 19 and 20 April 2022 and only 57 tablets remained of the 200 tablets dispensed, despite Child HR being in hospital at that time and only days having elapsed from when they were dispensed. No suicide note or any other indication of a plan to end her life (such as a will being left out) was located.130
At 8.07 pm, two detectives from Midland Detectives arrived at the house. They undertook a crime scene appreciation, to consider whether there was any evidence to suggest criminality, which might prompt a homicide investigation. Having noted the lack of evidence to suggest another person was involved and the absence of any injuries to HC, as well as the evidence of the large quantity of prescription 127 Exhibit 1, Tab 20.
128 Exhibit 1, Tab 2 – 3 and Tab 10.
129 Exhibit 1, Tab 2 – 3 and Tab 12.
130 Exhibit 1, Tab 2 – 3 and Tab 4.
[2025] WACOR 19 medication missing (and inferentially having been consumed by HC), the detectives concluded there were no signs of criminality. The detectives left the scene.131
Although the attending police officers and SJA officers did not observe a head injury when they viewed HC’s body at the house, a post mortem examination by a forensic pathologist found fracturing of the skull with bleeding over the brain, as well as congestion of the lungs (but no acute infection) and scarring of the kidneys. There was tablet residue present in the gastric contents, which was consistent with the evidence suggesting HC had taken a deliberate large overdose of tablets.132
Toxicology testing was completed, which showed amounts of ibuprofen and quetiapine, amphetamine and pseudoephedrine. In addition, aminoclonazepam and its active metabolite, 7-aminoclonazepam were detected. The levels of 7aminoclonazepam fell within the known toxic to fatal level. Alcohol was also detected at a high level in the blood (0.194%) and urine (0.247%). The forensic pathologist, Dr Jodi White, observed that the combined effects of the 7aminoclonazepam, quetiapine and alcohol would be markedly sedating leading to respiratory depression and compromise.133
Neuropathology of the brain was undertaken, which concluded there was a traumatic brain injury with an acute large extradural haematoma over the left cerebral hemisphere with midline shift to the right frontal lobe contusions.134
Note was made from previous multiple past neuroimaging reports that HC had had a number of past head injuries. The neuropathologist also observed that a recent CT in February 2022 had provided the comment that there was no intracranial haemorrhage. I note, HC had also been to hospital with another head injury, after reportedly falling in the shower, on 27 March 2022, but she had left the hospital before a CT scan could be performed.135
Police were advised at an early stage that the head injury had been detected and that the injury could be explained by a fall, but it was communicated to police so they were aware as part of their investigation, in case other evidence suggested a different cause, such as an assault.136
At the conclusion of all post mortem investigations, Dr White formed the opinion the cause of death was traumatic head injury with combined drug and alcohol effect.137
Given the finding of a head injury as a component of the cause of death, which was consistent with either a significant assault or a major fall, the WA Police reviewed 131 Exhibit 1, Tab 2 - 3.
132 Exhibit 1, Tab 7.
133 Exhibit 1, Tab 7 and Tab 8.
134 Exhibit 1, Tab 7 and Tab 9.1.
135 Exhibit 1, Tab 7, Tab 9.1 and Tab 18, p. 10.
137 Exhibit 1, Tab 7.
[2025] WACOR 19 the evidence to again consider whether there was any evidence to suggest another person was involved in her death. Detective Senior Sergeant Anthony Booker from the Major Crime Division had oversight of the coronial investigation into HC’s death. Det S/Sgt Booker confirmed at the inquest that a thorough initial police investigation, as well as further review, was conducted. At the end of the review, it was concluded that there was no evidence a third party was involved in her death.
The police noted HC had a history of falls with head strike when intoxicated, as well as past suicidal ideation. Further, her mental state at the time of her death had significantly declined due to Child HR’s removal from her care. The evidence located by police of the empty clonazepam medication, along with the toxicology analysis showing high levels of clonazepam and alcohol, indicated she had consumed an excessive amount of alcohol combined with medication that was not prescribed to her, on 22 April 2022, which made it very likely she fell after losing consciousness due to the combined effects of the alcohol and medication.138 Accordingly, Det Sgt Booker concluded the evidence obtained in the police investigation pointed towards suicide as the most likely manner of death.139
Child HR’s General Paediatrician had been her General Paediatrician since March 2018 and she was well acquainted with Child HR’s diagnosis and complex medical needs. Child HR’s General Paediatrician advised the Court that although cerebral palsy is not ‘progressive’, the complications of the condition, such as poor respiratory health and gastrointestinal dysmotility are, so her condition was lifelimiting. Child HR’s health had been deteriorating for some time, and she had been known to the PCH Palliative Care team for many years with a Goals of Care Plan in place since 9 December 2020. Further, HC had reported a gradual decline in Child HR’s health from around the beginning of 2021, with Child HR reported to be sleeping more and becoming unwell more quickly. This was reflected in her increasing number of hospital admissions for poor health from 2020 (predominantly for lower respiratory tract infections mostly secondary to aspiration) and noted increasing use of home oxygen when not in hospital.140
Therefore, at the time Child HR was admitted to PCH in April 2022, Child HR’s General Paediatrician was aware that Child HR was in declining health and could suffer a rapid deterioration at any time. However, she seemed generally stable at that time.
139 T 12 – 13; Exhibit 1, Tab 2 - 3 and Tab 18, p. 10.
140 Exhibit 2, Tab 12.
She assisted with Child HR’s personal possessions being collected from her home, in readiness for her new placement.141
On 28 April 2022, PCH advised Communities Child HR had contracted a respiratory tract infection and was assessed as high risk.142
Communities staff liaised with Child HR’s school and they agreed to inform Child HR of her mother’s passing in a way they felt she could understand and they also agreed to organise a box of memories of her mother for Child HR. This was completed on 5 May 2022 and arrangements were also made for Child HR to attend her mother’s funeral two days later.143
However, on 29 April 2022, Child HR’s father advised Communities he and his partner were no longer willing to care for Child HR, due to the amount of equipment required to care for her and concerns around finding a suitable space to accommodate her equipment in their current home. After a Needs Assessment had been conducted, they advised they would need a larger house before they could take her into their home. They began to take steps to secure an appropriate property for that purpose and Communities provided them with some assistance in their search.144
As a result, planning commenced to identify a suitable, home-like environment for Child HR to live where she could also receive the support she required. On 3 May 2022, Child HR was discharged from PCH and placed at Harry’s House, a disability respite support placement. Special Purpose Funding was arranged to facilitate the transition.145
Harry’s House supports children who have significant disabilities and complex medical needs, coordinating with their medical team at PCH to ensure the children they care for are managed safely in a more home like environment. It is clear that the staff at Harry’s House are dedicated and caring and they did their best to ensure continuity of care for Child HR, although it was somewhat hampered by the inability to speak to her mother, who had previously been the main overseer of Child HR’s care. Child HR was also in declining health by that time, which meant she couldn’t attend school regularly and also had a number of hospital admissions. Some of Child HR’s support workers who had been caring for her at her own home and were familiar with her ways of communicating and likes/dislikes, came to support her at Harry’s House. I have read through some of the notes written by Child HR’s support workers from May through to August 2022, while at Harry’s House and while she was in hospital. It is clear from the notes that the support workers were providing kind and supportive care for Child HR and the notes frequently record that she 141 Exhibit 2, Tab 9.1.
142 Exhibit 2, Tab 9.1.
143 Exhibit 2, Tab 9.1.
144 Exhibit 1, Tab 8 and Tab 9.1.
145 Exhibit 2, Tab 9.1.
[2025] WACOR 19 appeared happy, smiley and full of giggles during their shifts, even though her health was not always good.146
Child HR was only at Harry’s House for limited periods of time, due to her declining health. She had been taken by ambulance from school to PCH on 9 May 2022 due to respiratory distress and she was discharged two days later with a principal diagnosis of aspiration pneumonia. She returned to PCH on 17 May 2022 due to a further decline in her health detected when she was at school. She had been noted to be shallow breathing and struggling to clear thick secretions. She was admitted to ICU for a period and stabilised, before eventually returning to Harry’s House on 27 May
From 20 May 2022, Harry’s House staff observed Child HR was requiring increased amounts of suctioning and oxygen. She returned to PCH twice more in June 2022 for treatment for pneumonia.147
Child HR’s last admission to PCH was on 5 August 2022 after she began vomiting.
She did not return to Harry’s House after that, as her medical needs remained too great. Child HR’s father and maternal grandmother were notified of her hospital admission.148
Child HR’s General Paediatrician explained in her report that Child HR was admitted on 5 August 2022 with an increasing oxygen requirement, vomiting/feed intolerance and bradycardia (slow heartbeat). She was diagnosed with a lower respiratory tract infection. She was treated with oral antibiotics, intravenous hydration and respiratory support, as per her pervious agreed plan.149
On 8 August 2022 a multidisciplinary meeting was held. PCH staff reported that Child HR’s quality of life was fast deteriorating and it was expected that the trend over the long term in terms of her deteriorating gut function and respiratory function was not reversible. The doctors advised that further medical interventions were not in her best interests. Child HR’s father was consulted and he agreed the focus of care should be end of life planning as he wanted Child HR to have less intervention and not be in pain. Her Goals of Care Plan was updated to reflect this discussion. Child HR was kept comfortable, with optimal comfort treatment provided, until she passed away peacefully on the morning of 12 August 2022.150
147 Exhibit 2, Tab 9.1.
148 Exhibit 2, Tab 9.1.
149 Exhibit 2, Tab 12.
150 Exhibit 2, Tab 9.1 and Tab 12.
151 Exhibit 2, Tab 2.
He was spoken to by attending police and confirmed that Child HR had been in declining health since the death of her mother, and her death was not unexpected.152
Limited toxicology analysis showed the presence of medications used in medical and palliative care. Dr Junckerstorff formed the opinion the cause of death was terminal palliative care in a girl with a clinical diagnosis of aspiration pneumonia and cerebral palsy.153
Communities provided a very detailed report of their extensive interactions with Child HR and her mother, which spanned a period of approximately ten years, but with the most significant interactions from 2020 to 2022, when Child HR was twice taken into provisional care and protection on two occasions.155
The notable difference between the placement arrangements during the two periods of care is that:
• for the first period of care running from April 2020 to November 2021, Child HR still lived with her mother at her home in Roleystone but with significant additional supervision and supports in place;
• for the second period of care commencing in April 2022, Child HR was removed from her mother’s care and taken to PCH, and contact with her mother was restricted.
They believe the removal of Child HR from her home and her mother’s care led to both of their untimely deaths.
152 Exhibit 2, Tab 2 to Tab 4.
153 Exhibit 2, Tab 6 and Tab 7.
155 Exhibit 2, Tab 9.1.
In its report to the Court, Communities explained that during the first period of care, they had explored the option of removing Child HR from the family home. They had written to PCH in July 2020 requesting a medical opinion as to the consequences for Child HR should a change in placement occur, and PCH staff advised that Child HR was likely to appreciate a change in the location of her main place of care and it would take carers some time to understand the nuances of Child HR’s care, her communication needs and emotions and how to judge her settled and relaxed. It was suggested that ongoing significant contact with her mother, HC, might mitigate the possibility of detriment to Child HR from a change in location of care. Communities’ records reflected that HC had an intimate knowledge of HR’s medical and care needs, and it was acknowledged they had a close and loving relationship, so it was agreed that managing her within the home was the preferred option.156
Issues arose with some support staff during this first period of care, with HC notifying Communities twice that she was unhappy with certain support staff, and on both occasions the support service was notified and an agreement reached to provide an alternative carer.
The difference during the second period of care was that the primary support service, At Home Care, had reached a point where support workers were calling in sick as they did not want to go to the home due to reports of feeling unsafe, which removed the layer of safety that was in place. One of the senior Communities staff involved in the decision to remove Child HR from her home gave evidence Communities staff still had significant conversations around whether or not continuing to attempt to work within the home was appropriate, but the fact that similar concerns had been raised so quickly after the recent reunification following which Communities had closed its case, was also a large factor in the decision-making. The primary concern of Communities staff at that stage was that, due to substance use, HC would not be in a position to be able to meet Child HR’s complex care needs and support workers would not be available.157
158 Exhibit 1, Tab 11.1.
They accept that after HC’s death, the staff at Harry’s House provided the best care that they could, but it was obvious to them that without the loving and devoted care of her mother, Child HR deteriorated rapidly. They believe the effect of her changed circumstances hastened her death.159
Whilst I accept there is evidence before me that Child HR would have missed her mother and this would have negatively affected her mental state, I also am aware from the evidence before me that Child HR’s health was already in decline at the time she was taken into care. In the detailed Child Safety Investigation Approved Outcome Report prepared in February 2022, it was noted that Child HR was already in palliative care and therefore the quality of every day of her life needed to be taken into significant consideration. Communities was well aware, at the time she was removed from her mother, that Child HR had a limited life expectancy, but they were focussed on ensuring she remained safe and in an environment free from exposure to substance use for whatever time she had left. While I accept that she knew and loved her mother best, she had been interacting with her father for some time by this stage and the plan was to place her with her father and his partner. Heartbreaking as this would have been for HC, and also Child HR, the safety of Child HR was Communities’ primary focus and it was hoped she would be still living in a loving environment with one of her parents. Sadly, that did not eventuate as her father was still trying to obtain an appropriate house when Child HR died, but I consider it was a reasonable plan to implement at the time, and one that put Child HR’s safety first.
I note that in a previous inquest160 I have made comments about the need for Communities to take a robust approach to allegations of neglect in a child with complex disability, such as Child HR, given they are particularly vulnerable to the negative consequences of neglect and are often unable to communicate their needs to others. While I acknowledge the hurt and anger HC’s parents feel on behalf of their daughter, who they know truly loved Child HR, I also know as a coroner what can happen when the parent of a vulnerable child such as Child HR succumbs to substance use and neglects their duties as a parent.
I also acknowledge the extraordinarily difficult task HC was faced with, looking after a daughter she loved but who required constant care and supervision. Although extra support was offered to her, that support entailed strangers coming into her home on a daily basis. Ms Tracie Barker, who is the CEO of Harry’s House, has her own lived experience with caring for a child with complex needs, and she explained at the inquest how all-consuming caring for a child like Child HR can be, and unlike with most children, as Child HR grew older, her needs only increased. Added to those challenges are the complications of dealing with support staff as part of that care. Ms Barker explained that even with other people helping, ultimately for the parent, “it all stops with you” and the pressure of that responsibility is 24/7. There is little opportunity to sit down and relax when there are other people always present in your home, and those people may hold different values and different beliefs which conflict with your own. HC appeared to use exercise as a way of releasing some of her stress, and she also reached out to family and friends, but when they were not enough, she 159 Exhibit 1, Tab 11.1.
160 Inquest into the death of Child LT [2024] WACOR 14.
[2025] WACOR 19 turned to alcohol and medications to create that respite. While understandable, unfortunately this choice only created more stress in HC’s life.161
Ms Barker also identified the absence of respite options for HC, which may have made a significant difference to her mental state. Being able to take a brief holiday from the responsibility and family environment, while knowing Child HR was being well cared for, could have been an important circuit breaker for HC. It’s not clear what respite options were considered in this case, but I note that Harry’s House provides this service, and Ms Barker emphasised that this is the kind of option that NDIS should be including in their funding, with at least a month of respite care available to carers in cases like this. As Ms Barker noted, a month is not a lot when you consider that a child like Child HR is often receiving 24/7 care from their parent throughout the year, but it can make a major difference to the mental wellbeing of the parents.162
I recognise that HC’s parents did their very best to support her in her care of Child HR, as well as helping HC with employment and caring for her older son. However, there was only so much they could do to share the burden, living approximately 45 minutes’ drive away and with their own work and personal lives to manage. HC would also have known that they would be wanting her to prioritise Child HR’s needs, as she had shown she could do in the past, but addiction is a difficult thing to master, so admitting her lapses to her family may have been very hard for her.
Accordingly, HC’s parents felt that there was an opportunity missed for them to help their daughter at this last critical juncture.
I note below Communities has reflected upon their comments and acknowledged that wherever possible, including the extended family in safety planning benefits all involved. Some of the Communities’ staff also gave evidence that, in hindsight, holding a Signs of Safety meeting may have been a good opportunity to get firmer safety planning in place. There were concerns at the time that the members of the safety network, such as HC’s mother, had not previously followed through on safety plans and appeared dismissive of some of Communities’ current concerns about HC’s substance misuse. However, it was acknowledged that it was unclear whether family members were minimising concerns or whether they were not aware of the concerns. Therefore, an attempt to have that kind of round table meeting with extended family would likely have been a useful step in this case. At the very least, it would have ensured that everyone in the family understood what was likely to happen next if HC could not reduce her drinking and drug use, so that they all understood clearly that they were at a critical point.163
Such a plan would, however, require the cooperation of HC, who was not willing to attend face to face meetings. It was noted that child protection workers often face complex relationship dynamics in families, so it could not have been assumed that she gave her consent to her parents being brought into discussions without her agreement.164 Nevertheless, it was generally agreed by the witnesses that, in
163 T 93 – 95, 116, 119 – 120, 130 – 131, 142, 145; Exhibit 2, Tab 30 and Tab 31.
[2025] WACOR 19 hindsight, it would have been worthwhile exploring this option further so that a “final bottom line conversation”165 could have been had with all the relevant parties.
As suggested by one of the witnesses, involving the safety network more in the earlier discussions, before intervention action occurred, may also have given HC a better opportunity to have family supports around her, which may have changed the outcome for her. However, HC was reluctant to re-engage with Communities after only recently being reunified with her daughter, which made it difficult as she resisted face to face meetings. Therefore, there were limited opportunities for Communities to engage with HC, or even establish who she wanting to bring in as part of her support network this time, in the lead-up to the matter becoming urgent.166
As HC’s parents emphasised in their statement read out at the end of the inquest, they always made decisions that were in the best interests of their granddaughter, so whilst they would always provide support to HC, they would have done their best to help her to make decisions that ensured she could provide the best care to Child HR.
They note that no amount of documentation can ever replace personal contact, and suggest that holding a face to face meeting would have made a meaningful difference in this case.167
Prior to the inquest, Communities conducted an Internal Review into the circumstances of Child HR’s removal into protection and subsequent death. The Internal Review highlighted a number of developments since Child HR’s death. I have highlighted some of particular relevance to this matter.168
Communities has implemented significant changes to the way it approaches Family and Domestic Violence, which is underpinned by the principles and critical components of the Safe and Together Model. This may have been beneficial in the earlier period, when Child HR’s parents were still together and there were issues of family violence that could have been addressed, noting that HC’s fear of Child HR’s father being involved in their lives was a major factor in her mental health decline prior to her death.169
Communities has committed to deliver actions under Safe and Supported: the National Framework for Protecting Australia’s Children 2021 – 2031 (Safe and
166 T 131, 181; Exhibit 2, Tab 28.
168 Exhibit 2, Tab 25 169 Exhibit 2, Tab 9.2.
[2025] WACOR 19 Support Strategy), which outlines how governments and the non-government sector will work together towards the shared goal of making substantial and sustained progress to reduce the rate of child abuse and neglect and its impact across generations. Children and young people with disability are one of the four priority groups within the Safe and Supported Strategy. The Safe and Supported Child Protection and Disability Project, which comes out of the Safe and Supported Strategy, aims to substantially improve outcomes and experiences for children, parents and carers with disability or developmental delay who are at risk of, or are involved with, the WA child protection system. Communities is reviewing and updating specific guidance for staff to enhance culturally safe and responsive disability guidance.170
Further, it was noted that wherever possible, family members and significant others should be prioritised when making a care arrangement for a child in provisional protection and care, although noting that a safe parent will always be the primary option, as it was in Child HR’s case.171
It was never in doubt that HC absolutely adored her daughter, Child HR, and Child HR loved her mother in return. HC always made sure Child HR lived in a clean, beautiful, nurturing environment and that she received not only what she needed from a physical point of view, but what she needed emotionally to be a happy little girl. The sadness that everyone felt after Child HR’s death demonstrates what a delightful and very loved little girl she was, despite the many challenges she faced in her short life.
HC also faced challenges in her life, and sadly, she often responded to these challenges by abusing alcohol and prescription medications. Given Child HR needed help with all aspects of her daily living, and was prone to rapid deteriorations due to her respiratory and feeding issues, she needed a caregiver who was sober, present and able to respond quickly in times of need.172 There were periods of time, particularly as Child HR grew older and her health began to decline, when HC was not able to be that person.
It was always known that Child HR had a life-limiting condition due to the known complications of her cerebral palsy, and she had been on a palliative pathway since at least 2020. Ideally, she would have remained in her mothers’ care until the end, but 170 Exhibit 2, Tab 9.2.
171 Exhibit 2, Tab 9.2.
[2025] WACOR 19 unfortunately that was not possible as the concerns began to mount about HC’s sobriety.
It is clear that, despite HC being warned by Communities that if they had to intake Child HR again she would lose custody of her daughter, she did not fully understand the reality of that risk. I am certain if she had truly understood that she was risking losing care of her daughter and not being able to see her, she would have accepted more readily the offers being made to her for help. I also accept that it would have been preferable if HC’s parents had been more involved in the safety planning at the time, as they had been in the past, as this may have helped HC to gain some clarity about the potential consequences and make different decisions. However, I accept that at the time of making the decision to remove Child HR in April 2022, Communities had to act urgently and their limited interactions with the safety network had not given them any confidence that their involvement would change the situation. I accept that Communities staff made a difficult, but necessary, decision.
Tragically, when Child HR was removed from her mother’s care, the pain of losing her daughter in the midst of her already spiralling substance use and exacerbating mental health concerns, led her to take her own life. I have no doubt the loss of her mother from her life was upsetting and confusing for Child HR and would have made her last few months on earth less happy as a result. However, I also accept Child HR’s health was already in decline at that time.
I express my sincere condolences to Child HR’s grandparents and her brother, who have also lost a daughter and mother respectively, in heartbreaking circumstances.
I understand completely why HC’s family wish different decisions had been made, but having reflected upon the very long history between Communities and HC, and noting that their responsibility was to put the safety and welfare of Child HR first, I am satisfied they made the difficult but right decision to take Child HR into care.
S H Linton Deputy State Coroner 5 May 2025
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