The state’s coroner says the 2012 death of Chloe Valentine might have been avoided, had there not been systemic failures within welfare agency Families SA.
The bubbly, blonde haired toddler died of horrendous injuries after repeatedly crashing a motorbike she was forced to ride by her drug addict mother Ashlee Polkinghorne and then partner Benjamin McPartland.
Both are serving jail sentences for manslaughter by criminal neglect.
However the actions – or inaction - on the part of state government welfare agency Families SA has been scrutinised by Coroner Mark Johns, with scathing results.
The six week inquest found that family and friends has raised concerns for Chloe Valentine’s welfare on at least 20 occasions, yet Families SA continued to out the needs of the mother ahead of those of the child.
'Path of least resistance'
Coroner Johns described the system as broken and fundamentally flawed.
“They took the path of least resistance and the whole history of its dealing with Ashlee is a history of drifting, irresolution and aimlessness".
The inquest found social workers were inexperienced, couldn’t take notes or write reports and didn’t understand their responsibilities.
He added that there was a lack of analysis, a lack of clinical supervision and a lack of leadership.
Staff failed to report incidents of domestic violence and didn’t raise concerns about a convicted paedophile who was in a relationship with the child’s mother.
He said social workers ferried Ashlee Polkinghorne to appointments and provided financial support, yet it seemed Chloe’s interests had been forgotten completely.
Coroner Johns found that had Chloe been removed from her mother, she might be alive today.
"Nothing less than a massive overhaul of Families SA and its culture and training of its staff will be sufficient."
He’s made 22 recommendations for change – from straightforward improvements such as staff training, to more complex challenges, such as forced removal of children for their safety.
It includes a recommendation for removal at birth of children born to parents convicted of criminal neglect causing death, manslaughter or murder of a previous child.
It’s a recommendation welcomed by grandmother Belinda Valentine.
“It gives us some peace of mind, because it was a really big thing for our family that we’ve lost a little one, who can’t walk in the door at the end of the day, but we know that if another child is born that we can protect that child.”
Other recommendations include negotiating with the commonwealth to extend child protection Income Management more broadly than the program currently confined to Adelaide’s northern suburbs that expires at the end of June.
The coroner says a shortage of foster carers has prompted him to recommend that bad parents have their children permanently removed from them, and put up for adoption.
Attorney General John Rau has been tasked with overseeing the reform, and expects to implement all the coroner’s recommendations.
“I’m not here to defend the indefensible. I’m here to say that I welcome the coroner’s report I think it’s a very positive step towards us getting useful and productive change which will put the interests of children front and centre.”
The Opposition’s child protection spokeswoman Rachel Sanderson says the Liberal party has long argued for child protection to be taken out of the education portfolio and given special attention.
“In general I’m supportive of all the recommendations and we will go through one by one and work as best we can with government to ensure that they’re implemented as quickly as possible.”
The state’s Commissioner for Victims’ Rights is Michael O’Connell.
He broadly supports the coroner’s recommendations, but says they need to be managed carefully.
“The issue of adoption is one that has to be considered, has to be considered with care – care because we shouldn’t give up entirely on parents. We should be ensuring we have the appropriate means and mechanisms to support them in their times of need.”
Belinda Valentine had sought to adopt her granddaughter but was knocked back, and her concerns for Chloe’s safety were ignored.
She welcomes all the coroner’s recommendations relating to removal of children from unfit parents.
“I know for us, our worst nightmare was Ashlee having another child, and not being able to have the power to protect that child.”
Families SA is also the subject of a royal commission following allegations last year that a worker sexually abused 7 toddlers in his care.
