Coronial Inquest into passing of 12-year-old Sasha reveals gaps in child protection and healthcare systems

In late July, the findings from the Coronial Inquest into the passing of 12-year-old Sasha (pseudonym) were handed down.

Sasha passed away in hospital in 2019 while in out-of-home care. The Coroner found the cause of death to be complications resulting from pneumonia and heart valve infection in the setting of a heart abnormality that Sasha had. 

He also found that the relaying of critical medical information about Sasha were at points delayed, and not communicated effectively.

The Coroner made several recommendations to improve communication between the child protection and healthcare systems, including:

  • that the Department of Families Fairness and Housing (DFFH) review its Child Protection Manual and other relevant policies or guidelines to include guidance to Child Protection practitioners to seek, where possible, familial medical history that may impact the health of a child in its care.
  • that DFFH implement a means of effective urgent communication with its case-contracting agencies, supported by appropriate policy and procedures, in respect of a child in care. The means adopted should be available at all hours and capable of actively alerting the recipient.
  • that DFFH review its Child Protection Manual and other relevant policies or guidelines to make clear to case-contacting agencies, the circumstances in which it expects to urgently receive information concerning a child in care.
  • that Central Gippsland Health Service take all steps as may be required to eliminate facsimile transmission as the sole means of communication of critical clinical information.

Below is a statement from Sasha’s father, who VALS represented throughout the Inquest. 

“On July 17 we heard the Coroner’s findings from the Inquest into my daughter Sasha’s passing in hospital in 2019.

The Coroner identified areas for improvement in the child protection and healthcare systems and made recommendations to improve these systems.

One of the recommendations was about improving processes in the child protection system so that case workers try to gather important medical information like a child’s family medical history.

The Coroner also made recommendations to improve how child protection and contracted agencies manage children in care when they are admitted to hospital, and to improve the hospital’s communication of critical clinical information.

It brings me some closure to know that they’re starting to try to make changes to fix gaps in the system and that it’s because of Sasha that these improvements will happen. But at the same time I  wish that Sasha had the opportunity to have the benefit of these changes.

I miss Sasha, she was so bubbly and full of life. We were a big part of each other’s lives and always shared a special bond.

I hope that the changes prevent other children from experiencing what Sasha experienced.”


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