That is how Coroner Theresa O’Sullivan summarised her coronial inquest findings into circumstances leading up to the drowning of a boy by his mother at Moama.
The boy was drowned in 2017 in the Murray River, after he and his brother were taken from their home by their mother on March 1, 2017.
The mother drowned one of the boys and attempted to drown her other son on March 2, 2017.
She was found not guilty of murder on mental health grounds, after a Supreme Court judge found she suffered from a series of psychiatric conditions and held a delusional belief that she had to drown her sons in order to protect them.
The media is not able to identify the boy or his mother for legal reasons.
Fourteen months after the six-day coronial inquest was held at Deniliquin Coroner’s Court, the findings were handed down on Friday.
This inquest was not to discover how the boy died, rather it focused on potential shortcomings or inadequacies in the responses of involved agencies regarding the events that transpired prior to and on March 1-2, 2017, including in terms of compliance with applicable procedures and policies and the adequacy of them.
Ms O’Sullivan has made 17 recommendations for the NSW and Victorian Police Commissioners, the Department of Communities and Justice, Murrumbidgee Local Health District, the Catholic Education Office, and the Emergency Services Telecommunications Authority.
The inquest heard how the boy’s grandmother flagged down NSW police officers at 3am on March 2, 2017, to tell them her daughter had taken the children.
Ms O’Sullivan accepted that while there were no orders in place preventing the mother from taking her children, the fact the grandmother was seeking custody of the children “should have suggested the need for further inquiries”.
The grandmother attended the NSW station at 11.15am on March 2, saying her daughter had left town with the children, before telling officers at noon that she had received a call from her daughter in Goornong and was going to collect them.
The coroner found that the later officer’s approach to a risk assessment was “inadequate” and that he should have checked the police system for reports about the mother.
A 000 call was made on behalf of the grandmother where police were told of her concerns and that her daughter had said she was at a supermarket in Goornong.
Responding to the call, a police officer instead went to a supermarket in Huntly and not finding them there, broadcast a “keep a look out for” over police radio for the car that the woman was in.
At 3.45pm police were contacted after the mother stole from a service station in Elmore, but the mother was never found.
Ms O’Sullivan said while there was no evidence to suggest Victoria Police received a formal report that mother and her children were missing, she said that given police knew there was a concern for the welfare of the children and that their whereabouts was unknown, police could have considered whether the children met the missing persons criteria.
The coroner also referenced the fact that the mother had a mental health assessment at a Mental Health and Drug and Alcohol Service “sobbing and crying” the day before she took them, saying she did not want to continue living at her mother’s, and said a critical incident review had been done by the organisation the following month and recommendations implemented.
