Handing down inquest findings at Albion Park Local Court on February 26, Deputy State Coroner Geraldine Beattie lamented the loss of a young life. "This has been a very sad case," she said. "Deaths from asthma are relatively uncommon and [the girl's] death was so very clearly preventable. [She] was so young when she died and her experience of childhood fell below what we would hope was acceptable." The girl's history of chronic asthma dated back to 2005. She was admitted to hospital for four days in 2011 and was prescribed a puffer (Salbutamol) and the asthma preventer Singulair, but overly relied on the puffer and tended not to use the preventer. The day before her death, the girl's parents drove to the Warilla Hotel for Anzac Day two-up some time after 11am, leaving her at home asleep. They returned about 4pm to find her complaining of asthma and yelling and crying for her misplaced puffer.

Her condition fluctuated in the hours that followed. She could cry and scream, then settle and play with the cat, then panic and plead and yell for her puffer, her breathing short and wheezy. The inquest heard it was common for the girl to misplace her puffer and panic, but she was "more on edge" than usual, enough for her mother – who could not drive due to mental illness – to make an unprecedented request for the girl's father to take her to hospital. All of these factors paint a picture of a family struggling to cope with day-to-day life. Coroner Geraldine Beattie The father told the mother he had been drinking and she should call an ambulance. Ultimately, neither parent attempted to get the girl to hospital or to obtain a new puffer on the evening of the public holiday. The father "simply went back to bed in the garage and removed his hearing aids", Coroner Beattie noted.

"[Her] parents appear to have paid little heed to her condition." The girl's brother saw her asleep and breathing in her mother's bed about 2am. Some time later she went into the lounge room, slumped over and stopped breathing. Her father made the discovery at at 6.50am. In a harrowing triple-zero call played for the inquest, the girl's mother screams hysterically in the background. She was rushed by ambulance to Wollongong Hospital emergency department, to be declared dead at 9.05am after further resuscitation efforts failed. Medical records show the girl's family was given asthma education sessions during doctor's visits and her 2011 hospital stay. But her parents missed multiple follow-up appointments aimed at delivering further education and she ultimately did not follow her treatment regime. The girl's father, who filled her scripts, told the inquest he did not know she was supposed to take the Singulair daily. "Attempts to educate [the girl] and her family and to have them understand and adhere to an asthma management plan were unsuccessful," the Coroner said.

Police notified of the girl's death were met by a "foul odour" as they attempted to enter the house and they retreated for protective masks. Correspondence from Housing NSW detailed the extent of the mice infestation and mould, though the inquest could not establish how long the house had been in this state. The inquest heard medical evidence that the environment had likely contributed to the severity of the girl's asthma, as had her passive exposure to her father's smoking and her morbid obesity. The girl's father gave evidence of his increasing inability to cope as the behaviour of the girl - and her mother - deteriorated in the year leading to the death. She suffered behavioural problems including Oppositional Defiance Disorder and Attention Deficit Hyperactivity Disorder, which may have made it difficult for her family to know whether she was acting out or suffering genuinely dire health troubles, the inquest found. "All of these factors paint a picture of a family struggling to cope with day-to-day life," Coroner Beattie said.

Family and Community Services had some early involvement with the girl's family through the Brighter Futures program in 2006-2008, but the inquest heard this mainly involved enrolling the children in extra-curricular activities, providing occasional financial assistance and referring the girl's mother to a parenting program, which she never attended. The final report to Family and Community Services – concerning the girl's very poor hygiene – was lodged on June 5, 2013. It was one of three reports the department "closed due to competing priorities". The term was reflective of "limited resources being stretched to the limit", Coroner Beattie said. The coroner accepted the department was "treating the lessons to be learned from [the girl's] tragic case very seriously and is endeavouring to share these lessons with frontline staff." She also noted: "It is clear from this table [of reports to FaCS] that there were too many missed opportunities for FaCS to investigate and take supportive and/or protective action". She recommended that the department lead a discussion among the region's Joint Investigation Response Team (JIRT) about developing a training package to identify and respond to chronic neglect, including medical neglect.

"While [the girl] was undoubtedly loved and is mourned by her family, it is clear that they had limited personal resources to look after her physically and emotionally particularly as her complex needs increased and her behaviour deteriorated," the Coroner said. Illawarra Mercury