Chloe Valentine inquest: SA child protection system broken, massive overhaul needed, coroner says

Updated

The death of four-year-old Chloe Valentine occurred after the agency tasked with her protection, Families SA, took the "path of least resistance" and proves the state's child protection system is "broken and fundamentally flawed", a coroner has found.

Chloe died from horrific injuries after repeatedly crashing a motorbike she was forced to ride over several days at a home in Ingle Farm in Adelaide's north in January 2012.

Her mother, Ashlee Polkinghorne, and Polkinghorne's partner at the time, Benjamin McPartland, were jailed for manslaughter by criminal neglect.

South Australian coroner Mark Johns, handing down his findings into Chloe's death today, recommended sweeping changes to the state's child protection services.

"Nothing less than a massive overhaul of Families SA and its culture and training of its staff will be sufficient," he said, adding that the government agency "took the path of least resistance and the whole history of its dealing with Ashlee is a history of drifting, irresolution and aimlessness".

Polkinghorne was a heavy drinker and drug addict who used methamphetamine and cannabis.

More than 20 notifications were made to Families SA before Chloe's death from family and friends who were concerned for the little girl's welfare.

Many of those concerns were largely ignored by the agency.

Key recommendations: Any parent convicted of manslaughter or murder of a child should automatically have future children removed from their care at birth

All social workers with less than 12 months' experience should be supervised

An "urgent re-education" to rectify widespread misunderstanding that parents have to be consulted on any care decisions about their child

A requirement for social workers to be registered

The State Government begin negotiations with the Commonwealth to make a child protection income management regime permanent

That permanent removal of children to adoptive parents has a place in the child protection scheme

Mr Johns described Families SA as "broken and fundamentally flawed" and recommended that laws are changed so that anyone convicted of manslaughter or murder of a child would automatically have any future children removed from their care at birth.

He said a child should only be returned to their parent's care if they can prove to a court that they are fit to be a parent.

Mr Johns said he was of the firm opinion that permanent removal to adoptive parents should have a place in the child protection system, particularly in light of a "notorious under supply" of suitable and willing foster parents.

He said only 114 Australian children were adopted in 2009 to 2010, compared to more than 8,500 in the early 1970s.

Mr Johns also called for a requirement that social workers had to be registered and recommended that all social workers with less than 12 months' experience be supervised by senior workers when having contact with clients.

He called on the State Government to begin negotiations with the Commonwealth to make a child protection income management regime permanent that ensured welfare payments were being spent on essential items.

Polkinghorne 'fooled' social workers

Mr Johns said Polkinghorne fooled social workers and used Chloe as a bargaining chip to manipulate friends and Families SA.

He said she had a selfish lifestyle that prioritised her own interests above Chloe's and, had the child been removed from Polkinghorne's care, she would probably be alive today.

Mr Johns said Families SA should have used all the legislative tools available to help the child and called it "preposterous, frightening and concerning" that two social workers did not tell Polkinghorne that her previous partner was a convicted paedophile.

He also recommended that Families SA "urgently re-educate" all staff to rectify widespread misunderstanding in the organisation that a parent has to be consulted about any care decisions about their child.

Beginning in September 2014, the inquest into Chloe's death has heard from 39 witnesses, including Families SA social workers and supervisors, those that made notifications to the agency before her death, and Chloe's grandmother, Belinda Valentine.

Ms Valentine gave evidence that she wanted to take her granddaughter into her care but was not supported by Families SA.

She welcomed the coroner's findings today and called on Premier Jay Weatherill to accept the recommendations.

"He needs to take his job very seriously," Ms Valentine said.

"He is the leader of our state, he is the leader of us, he is the leader of our children.

"And our children deserve nothing less than that."

Child Protection Reform Minister John Rau said he was not shocked by any of the recommendations and is broadly supportive of all of them.

"I will have to go to Cabinet to get decisions about those sorts of matters," Mr Rau said.

"All I can say is that from my personal point of view on the surface they sound perfectly rational things to be considering at least in as much as we are trying to focus on the welfare of children."

The Opposition spokeswoman for child protection, Rachel Sanderson, said the Liberal Party wanted to see action on the recommendations.

"In general I'm supportive of all of 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," Ms Sanderson said.

During the inquest, Families SA chief executive officer Tony Harrison conceded that Chloe could have been removed from her mother's care as early as 2008.

He said he was confident recommendations made by the coroner would lead to a better child protection system and the agency had being trying to implement changes since Chloe's case came to light.

The agency is also the subject of a royal commission into SA's child protection system after allegations surfaced last year that a Families SA carer sexually abused seven toddlers in his care

Topics: child-abuse, community-and-society, courts-and-trials, law-crime-and-justice, murder-and-manslaughter, ingle-farm-5098, adelaide-5000, sa

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