Coroner: Queensland should actively pursue adoptions of children in care to avoid deaths of children like Mason Jet Lee

In scathing findings, the Queensland Coroner investigating the death of toddler Mason Jet Lee has slammed the continued failure of the Queensland Department of Child Safety, Youth and Women to consider adoption of children in care. Mason Jet Lee was killed by his stepfather. The coroner, Jane Bentley said: “Mason Jet Lee was 22 months… Read More »Custom Single Post Header

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Coroner: Queensland should actively pursue adoptions of children in care to avoid deaths of children like Mason Jet Lee

In scathing findings, the Queensland Coroner investigating the death of toddler Mason Jet Lee has slammed the continued failure of the Queensland Department of Child Safety, Youth and Women to consider adoption of children in care.

Mason Jet Lee was killed by his stepfather. The coroner, Jane Bentley said:

“Mason Jet Lee was 22 months old when he died. He was totally dependent on others to feed, nurture, love and care for him. Those who should have cared for and protected him allowed him to be abused and neglected to the point that the injuries inflicted on him caused his painful and prolonged death.”

The Coroner’s recommendations about adoption were to the point:

(a) The department review its policies and procedures to ensure that, in accordance with the Government’s acceptance of Recommendation 7.4 of the Carmody Inquiry: i. adoption is routinely and genuinely considered as a suitable permanency option for children in out-of-home care where re-unification or unification is unlikely, and should be pursued in those cases, particularly for children aged under 3 years. 
ii. Adoption is routinely and genuinely considered by Child Safety officers as one of the permanency options open to them when deciding where to place a child in out of home care. 
(b) The Government consider whether the Adoption Act 2009 (Qld) should similarly reflect the 2018 amendments to the Adoption Act2000 (NSW), expecting children to be permanently placed through out of home adoptions within 24 months of entering the department’s care. 
(c) The department report to the Coroners Court of Queensland the numbers of children adopted and the details of those matters, every six months for the next five years.

 The coroner rejected the Department’s view thatthe failures which led to Mason’s death were the result of overworked, under-resourced and inexperienced staff which is the result of an increased demand for services i.e. an ever increasing number of children requiring protection.” 
Instead, if the Department had followed through with the recommendations of the Carmody inquiry to ensure that children like Mason were adopted,  and therefore removed from the system, then he would not have remained at risk in his mother and stepfather’s care (and would not have died).
The coroner was scathing about the Department’s failures:
“Every Child Safety Officer and Senior Team Leader involved in Mason’s case was more concerned about Ms Lee and her issues than ensuring the safety of Mason and his siblings. Whilst it is accepted that supporting families is a recognised and successful method of keeping children with their parents and out of the child protection system, that consideration cannot override the primary consideration of protecting vulnerable children. In this case supporting Ms Lee continued to be the main focus long after it became evident that Mason was at serious risk of harm and long after proper investigations would have revealed that he was not in the care of the person that all resources were going to support i.e. Ms Lee.



I conclude that the department failed in its duty to protect Mason from the risk of serious harm that he faced in the months prior to his death. Indeed, it is difficult to find any step taken in this case that was carried out in accordance with policies and procedures and correctly documented. The fact that the Ethical Standards Unit found that 21 employees of the department involved in Mason’s case (10 at Caboolture Child Safety Service Centre and a further 11 employees involved in intakes) failed to carry out their duties appropriately is indicative of the scale of the failure….



None of the Child Safety Officers conducted an appropriate investigation, none of them took the time to look at the information held by the department, they did not submit information to SCAN or look at information from SCAN, they did not appropriately consider information provided by the hospital, they failed to make case notes and they submitted inadequate documents for approval. However, none of the team leaders or Manager 1 took any steps to ensure that the CSOs were dealing with Mason’s case appropriately.



Whilst Manager 1 might have been liked by a number of the staff on a personal level she was not undertaking her managerial duties in an adequate or appropriate manner. The CCSSC was chaotic. There was no supervision. There was no compliance with basic procedures and policies. Nobody understood how the matrix model was working (including Manager 2). STLs were conducting the work of CSOs rather than supervising them. I can only infer that either Manager 1 was unaware of the fundamental failures that were occurring in the office she was responsible for managing or that she knew of the issues and ignored them. In either event she was not undertaking her managerial duties.



I do not accept that Manager 1 was unaware of the issues surrounding STL4 until early April 2016. I find that she was aware of the problem at least one year before that but did not deal with it even though it was significantly affecting the service delivery of the CCSSC.908. Manager 2 and the Acting Manager identified numerous issues of significant concern shortly after each commenced in CCSSC and then took steps to remedy those issues. These included the confusion surrounding the matrix model, the lack of process for allocation of cases and the fact that STLs were conducting case work rather than supervising.



The errors and failings of the individual employees of the department were merely the component parts of the collective failure of the department.



The failings occurred in a context complicated by issues of mental health, domestic violence, drug and alcohol abuse, homelessness, poor socio-economic status – all of these issues were present for Mason’s family.



Families that come into contact with the department are typically becoming increasingly complex, with significant needs across multiple disciplines. Sadly, Mason’s family situation was not unusual. Statistics collated in November 2019 in relation to families involved with the department demonstrate:


a. 66% of households substantiated for harm or risk of harm to a child had a parent with a current or past drug and/or alcohol problem;


b. 50% of families had been impacted by domestic and family violence in the past year;


c. 42% had a parent who had been abused as a child;


d. 53% had a parent with a criminal history;


e. 53% had a parent with a diagnosed mental illness;


f. 74% of households had a combination of these factors.



Every one of these factors was present for Mason’s family. 


Increased Demand on the Department



Funding for child protection is constantly increasing.



Methamphetamine use by one or more parents continues to be recorded for approximately one in three children subject to ongoing intervention which has required additional resources.



It is becoming more difficult for the department to recruit staff. In 2016 there were 1343 applications for CSO positions – in 2019 there were just 692.



The department cannot retain staff. Almost one fifth of CSOs left the department in 2018 – 2019. The high turnover creates a difficulty in regard to the retention of knowledge.



I find that the department has high percentage of inexperienced staff who are constantly having to deal with new models, policies, procedures and training modules as the department implements numerous recommendations arising from the many reviews of unfavourable outcomes for children in its care.



Removing Children from the System



Despite successive governments providing ever increasing amounts of funding for the child protection system and the government’s continuing attempts to improve the system, it continues to be overwhelmed by an increasing number of children being introduced to it. The reasons for this are not within the scope of this inquest but, as acknowledged by the department, include the ice epidemic which has been the scourge of our community and our families for some years and shows no signs of abating.



The recommendations resulting from the Carmody Inquiry included recommendations designed to remove children from the system. That has not occurred.



As was fully explored and accepted by the Carmody Inquiry, adoption is a method of removing children from the system. Further it recognises the child’s rights to be protected above those of parents who are unwilling and/or unable to appropriately care for those children.



The emphasis for child safety in Queensland, demonstrated by this case and acknowledged by the Ethical Standards Unit, is maintaining family unification or re-unification. That is a philosophy which is oriented towards parents’ rights to family rather than a child’s unquestionable right to be safe.



The Carmody Inquiry report stated:



The Commission recognises that adoption may be a suitable permanency option for some children in out-of-home care and should be pursued in those cases, particularly for children aged under 3 years. As such, adoption should be routinely and genuinely considered by Child Safety officers as one of the permanency options open to them when deciding where to place a child in out-of-home care. Given the polarising nature of this placement option for children in out-of-home care, careful consideration must be made before selecting this option. An experienced and judicious approach must be applied to the balance between family preservation and adoption. The Commission acknowledges that adoption within child protection is a contentious issue in Australia; however, while family preservation remains the preferred policy approach, adoption will remain as one option in a suite of permanency options.



Publicly available expert evidence given before the Carmody Inquiry explains the reference to under three years of age in the quote above. In short, well respected medical specialists such as Dr Elizabeth Hoehn and Professor Stephen Stathis gave evidence that a child’s first two to three years are formative for developing secure attachments, healthy development and solid neural pathways:



MS McMILLAN: And the fact that they may then have children with that cycle continuing?-



–That’s right, yes.



Can I just ask you just in terms of those issues, I take it you know Dr Elizabeth Hoehn?—I do.


All right. Now, in her statement she talks about “Extensive research” -this is page 5 for anyone who wants to follow it – has demonstrated the importance of the early years of a child’s life, especially the first three years in laying the foundation for healthy development and resilience. The brain changes throughout life but it’s in the changes in the first three years of life that will have the greatest impact on expressing the brain’s potential. Are you aware of that extensive research?—Very well.Is it, in your view, fairly much accepted within the psychiatric world that that’s correct?—



Absolutely; no question.



All right. She says later, amongst many other things: Crucial pathways needed for neuropsychological processes such as attention,learning, memory, recognising and regulating emotions, impulse control and speechand language develop during these first three years?—



Yes, I’m aware of two really important studies, if you don’t mind me elaborating.



COMMISSIONER: No, please?—



The first is the Bucharest Early Intervention Project which is now over 10 years old and what they did is they actually took children who were in institutions in Romania and put them into foster placement and they – but it’s different from the foster placements we have here. They trained these foster mums up. They paid their foster mums a good wage. It’s a European model. These kids were taken and placed in the foster placements. Now, they did it randomly which sounds like an ethical dilemma but the reason they could do that is Romania had no foster placement ethos anyway so they came in and said, “We’ve got this amount of money. We can’t look after all kids but we can randomly assign children,” and they assigned them from birth onward and this is what they found. They’ve followed these children up. This is good foster placement. If the children were placed in foster care before the age of two, they had significant improvements in IQ; in a whole range of mental health issues. EEG changes showed that their brain was recovering, so to speak. After the age of two no change; didn’t matter; good foster parents, good foster mums, good foster dads; didn’t matter.



Irreversible?—Irreversible, and they’ve continued that study on. Because now it’s a longitudinal study, we’re getting increasing evidence that this is the case. You’ve got two years. You’ve got two years. Dr Hoehn said three. I respect Dr Hoehn, but from the Bucharest study you’ve got two years. If you don’t act within two years, the door’s closed.



All right, so if we can give them a protective, developmentally friendly environment up till three can they withstand a different environment, much more coercive, intrusive, traumatic, for longer as a result of the benefits that they had pre three?—Their brains and themselves by definition therefore have a greater capacity for resilience. …… If we do that until they’re three they’ve got more of a chance of surviving what else comes?—Yes. Well, if we do that by three we’re giving the brain a better chance, a better opportunity, to develop normally.



Professor Stathis also noted:if it [support for parents] does not work the child needs to be taken and permanently placed elsewhere. That’s my view.



COMMISSIONER: How long will you give it to work? —We’ve got two years, three years, based – if you want the evidence, three years based on the evidence. You don’t have a long time, okay.



Okay?—I mean, you could have permanent placement later of course, but I’m talking about children who are identified at birth?— At birth or soon after.



Soon after?—Okay.



Yes?—But for that to work as well that second plank has to have foster parents who also have been trained and educated up and they see it as a vocation and they’re paid well too. They’re given one, two, three kids, a few kids, and this is their family. I don’t care whether you call it adoption or permanent placement or whatever. This is their family until 18 or beyond, okay. This is their family. That’s the second plank, but there’s a third plank, and the third plank is we can’t forget the mums, or often it’s the girls, whose kids have been taken from them, because I’ve worked in a detention centre. These children, and I’ll use the word “children” – – – Children – – -? — – – – who are having children – – –



Child parents?—Yes. They want the child. They will say they want the child because they want someone to love them. That’s the irony. They want the child to love them, and it’s because they’ve never been loved. “So I’ll have a child and they can love me.” Now, if all you do is take that child from them and you stigmatise them and you crush them, they’re just going to have another child. To replace the love that they didn’t get from the first one?



—To replace – because that’s the only way they’ve found love. So the child who’s having the children has to be nurtured themselves so we can’t forget the third plank because if you leave out the third plank, you’re just going to have them having more and more children. That’s not child’s best interests and it’s not in the child’s child’s best interests either.



The Queensland Government has recognised that adoption ought be an option in accepting Recommendation 7.4 from the Carmody Inquiry:



The Department of Communities, Child Safety and Disability Services routinely consider and pursue adoption (particularly for children aged under 3 years) in cases where reunification is no longer a feasible case-plan goal.



Although it is the position of the department that the recommendation in regard to adoption has been implemented by the department it is obvious that it in fact has not been implemented in any real sense. From 2013 to 2019 a tiny handful of children have been adopted from out of home care. Thirty-two permanent care orders have been made since October 2018.



However, as at 17 March 2020, 6,795 children were subject to Long Term Guardianship Orders i.e. under the care of the department until they turn 18 years of age on the basis that they have no parent willing and able to care for them and they will not in the foreseeable future.



The New South Wales current position is briefly summarised as:



Every child and young person deserves the chance to have a permanent home for life where they can feel loved and secure. Under the Permanency Support Program introduced in October 2017, a child or young person will have a case plan with a goal to have a safe and permanent home within 2 years of entering care. Where returning to their birth family or guardianship to a relative, kin or other suitable person is not practicable or in the best interests of the child or young person, open adoption will be considered. In the case of an Aboriginal or Torres Strait Islander child or young person placements should be in accordance with Aboriginal and Torres Strait Islander Child and Young Person Placement Principles in the Children and Young Persons (Care and Protection) Act 1998.



The department submits that these findings should not comment on adoption of children as it was not an issue to be explored at this inquest and was not in fact explored at the inquest.



I disagree with that submission. The main issue to be explored at the inquest and the task I am bound to undertake is the identification of ways of preventing similar deaths in future.



The department submits that the failures which led to Mason’s death were the result of overworked, under-resourced and inexperienced staff which is the result of an increased demand for services i.e. an ever increasing number of children requiring protection.



Although the issue of adoption was not explored at the inquest, it was fully explored by the Carmody Inquiry and the department has given evidence that Recommendation 7.4 from the Carmody Inquiry, which was accepted by the Government, has been implemented.



The numbers of children on long term orders as compared to those on permanency orders or those who have been adopted reveals that the Carmody recommendation has not been implemented in any real sense.”


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