A morbidly obese 13-year-old girl who died following an asthma attack could have been better protected and supported by the NSW government's Family and Community Services Department, an inquest has found.
The girl, who can't be identified, died at Wollongong Hospital in April 2014 after being found not breathing in the lounge of her "putrid" family home which was "heavily infested with mice", NSW Deputy State Coroner Geraldine Beattie said in her recent findings.
"There were too many missed opportunities for FaCS to investigate and take supportive and or protective action," Ms Beattie said.
A table in the findings shows 19 reports were made to FaCS about the girl between October 2002 and June 2013.
"Very poor hygiene, wearing the same clothes for months on end, smells terribly, menstruating through clothes," is a description of one of the matters reported to FaCS presented in the inquest.
The girl had learning and behavioural issues and was morbidly obese, weighing 112.5 kilograms at the time of her death.
Her family also struggled with everyday life.
"(Her) parents were just not coping with such demands of everyday living as basic hygiene, cooking, cleaning and routine," Ms Beattie said.
After years of interaction with police, FaCS and other services, the government in June 2013 decided to close her case "due to competing priorities".
While budget constraints factored into the decision, Ms Beattie found the girl's death was not "just simply a resources issue".
Internal processes meant other cases deemed to be more acute were given preference over the girl's more chronic matter, Ms Beattie said.
However, she did find that the girl should have been taken to hospital when she complained of an asthma attack on the day before she died.
"There she could have received appropriate life-saving treatment," Ms Beattie said.
The death might have been avoided if her parents, who had mental health issues, were able to attend to her basic health needs.
FaCS had also failed to identify "the serious and chronic neglect issues", which could have led to them removing the girl from harm.
"(The girl's) death was so clearly preventable," Ms Beattie said.
"This has been a very sad case."
