Los “otros” verdaderos retratos

Despite the particular vulnerability of children in the early years, neglect continues to be responded to less frequently and in a less timely fashion than physical and sexual abuse. The results of the incidence study in Chapter 4 confirmed that neglected infants (under 48 months of age) were being referred and re-referred to the Department at an

unacceptably high rate. The rate at which referrals are repeated provides a measure of the overall effectiveness of the child protection system in place at the time – with a high

re-referral rate indicating an inadequate child protection response (Forrester 2007). Jacob and Fanning’s (2006) report on child protection in Tasmania was one of a number of reviews and reports which confirmed that the system at the time was failing,

particularly in relation to a highly vulnerable group of infants on unallocated lists awaiting further investigation and assessment.

An investigation into the deaths of ten children in Tasmania in 2005 and 2006 was conducted in order to “identify any factors that may have been involved in their quality of life and any overall systemic issues related to the child protection” (Minister for Health and Human Services, 28 November 2007).34 Although the report was not publicly released, a ministerial media release revealed that of the eight children who were actually known to Child Protection at the time,35 three were reported to have died as a result of abuse or neglect, two infants were found to have died of sudden infant death syndrome (with risk factors present), and three children died from natural causes or as a result of a disability. It is likely that at least two of the deaths were subject to coronial inquiries and/or police investigations which had not been finalised at the time. That review and the separate investigation into the death of another child resulted in a lengthy set of recommendations which were being gradually implemented along with the other major reforms and changes to the child protection system outlined in Chapter Two.

There is a lack of accurate statistical data on child deaths in countries such as Australia, and while physical assault is usually included in paediatric death reviews, neglect usually is not (Lamont 2010; Sidebotham, Bailey, Belderson & Brandon 2011). However, the NSW Child Death Review process does include neglect and abuse classifications, and in the Ombudsman’s review of 45 deaths of children in NSW in 2009-10, for example, 29 cases (or 64%) were classified as having occurred in relation to abuse, neglect or suspicious circumstances; of these deaths, fourteen (31.1%) were due to neglect, seven (15.5%) were due to abuse, and eight (17.7%) occurred in suspicious circumstances (Lamont 2010, p. 3).

34 _{Media Statement by then Minister for Health and Human Services, Lara Gidding (28 November 2007)} 35 _{It is likely that the families of the two children not finally included were known to the Department, but}

Nonetheless, the number of fatalities due to neglect is believed to be an underestimate of the true incidence, partly due to the unresolved issues surrounding the definition of neglect and partly due to the fact that there are often unresolved questions surrounding the circumstances of paediatric and perinatal deaths (e.g. American Academy of Pediatrics 2001; Lawrence & Irvine 2004). For instance, in the New South Wales (NSW) Child death Review Team’s (2003) report, neglect is conceptualised in terms of parental actions and failures which only include inadequate supervision (e.g. drowning), negligent driving, and failure to provide medical care (NSW CDRT 2003).

The NSW Department of Community Services’ (DoCS 2006) policy on child neglect was developed partially in response the prevalence of neglect concerns being notified to the department and increased understanding of its adverse affects on child development, but also in response to the Child Death Review Team’s criticisms of current practices in relation to neglect. In particular, the Team referred to the commonly held misconception that each neglectful incident is trivial and less serious than physical or sexual abuse; thereby affecting both the type of response and the priority that it is assigned. The “critical issues adding impetus to better understand the nature of neglect in all the forms in which our caseworkers encounter it, both in isolation and entangled with other forms

of abuse” (p. 9), which are equally pertinent to the current study, are:

- the sometimes fatal consequences of neglect, and the disturbing fact that the

characteristics of families in which neglect-related deaths occur are not distinguishable from the characteristics of families in which neglect is chronic;

- the prevalence of neglect as an underlying or co-existing factor in cases featuring both abuse and neglect, with the consequence that neglect may not receive appropriate attention;

- and the impact of neglect on both child development and functioning in later life (DoCS 2006, p. 9).

Examining cases where serious harm has occurred enables an exploration of the relationship between neglect and other forms of abuse. Sudden unexpected or

unexplained death in infancy is the main cause of death of children between one month and one year of age in Australia and the US (Qld Government 2008). At the time of writing there is, as yet, no formal child death review process in place to routinely provide analyses or to report on the deaths of children known to child protection in Tasmania; however, the Department has been working towards bringing together the existing review mechanisms – the Council of Obstetric and Paediatric Mortality and

Morbidity (COPMM), the Coronial process, and child protection – with the aim of establishing a review body such as a child death review committee (Lamont 2010). The unexplained deaths of nine infants in Tasmania in 2005 and 2006 were found by the COPMM to have been attributable to unsafe sleeping practices and/or environments together with exposure to additional risk factors such as maternal alcohol, cannabis, tobacco or other legal and/or illegal drug use, with accidental overlying and/or

respiratory failure evident in some of the cases (COPMM 2005, 2006 in DHHS 2007, 2008).36

Although all of the deaths were classified as either ‘sudden infant deaths’ (SIDS) or ‘sudden unexplained/unexpected death of an infant’ (SUDI), the Council of Obstetric and Paediatric Mortality and Morbidity (DHHS 2007) commented that in light of the findings, it was “evident that the nature of unexplained infant deaths had changed over the years” (p. 25). There are, however, some differences worth noting between the Tasmanian COPMM’s definition and usage of the Acronyms SIDS and SUDI and that described in the Public Health Association of Australia’s policy document outlined below. The Tasmanian COPMM defines SIDS and SUDI as follows:

Sudden Infant Death Syndrome (SIDS): Sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation including performance of a complete autopsy, examination of the death scene, and a review of the clinical history. The term Sudden Unexplained Death of an Infant (SUDI) is now often used instead of

Sudden Infant Death Syndrome (SIDS) because some coroners prefer to use the term 'undetermined' for a death previously considered to be SIDS. (COPMM 2011; italics added)

The Public Health Association of Australia, on the other hand, uses the term

‘unexpected’ rather than ‘unexplained’ to define SUDI, and conceptualises SIDS as a subset of SUDI, as follows:

Sudden Unexpected Death in Infancy (SUDI) is the sudden, unexpected death of an infant, usually occurring during sleep, in which a cause of death is not immediately obvious. SUDI refers to a broad category of sudden and unexpected deaths which include Sudden Infant Death Syndrome (SIDS), infections or anatomical or developmental abnormalities not recognised before death, sleep accidents due to unsafe sleep

environments and sudden unexpected deaths that are revealed by investigations to have been the result of non-accidental injuries (QLD Health 2008).

A death is generally classified as a SUDI if it concerns: • an infant less than 12 months of age

• a death that was sudden in nature

36_{The Council of Obstetric and Paediatric Mortality and Morbidity’s (COPMM) Annual Reports are available at:}

• a death that was unexpected (QLD Health 2008). SIDS is a subset of SUDI. SIDS is defined as:

The sudden and unexpected death of an infant under 1 year of age, with onset of lethal episode apparently occurring during sleep, that remains unexplained after a thorough investigation including performance of a complete autopsy, and review of the

circumstances of death and the clinical history. (July 2004) (Public Health Association of Australia 2009)37

The forensic pathologist in another SIDS investigation makes the additional point that “it is not possible, within the current state of medical science, to distinguish death due to the sudden infant death syndrome (SIDS) and suffocation due to compression by an overlaying adult ... the autopsy findings in cases of SIDS are variable and non-specific” (Record of Investigation into Death, 2009). Tasmanian coronial records reveal that 33 of the 34 infants who died between May 1999 and July 2006 involved an unsafe sleeping environment – predominantly co-sleeping in an adult bed and unsafe bedding – with many of the deaths also involving factors such as parental alcohol and/or drug use and cigarette smoking (Coroner’s Findings, 2008)38.

The record of investigation into the deaths of four of the infants in 2005 and 2006 was published “in order to emphasise the significance of the issue in Tasmania in the hope that consideration can be given to ways in which further similar deaths can be

prevented” (Coroner’s Records 2008). Both the Coroner (2008) and the Council of Obstetric and Paediatric Mortality and Morbidity (DHHS 2008b) have expressed concern about the high rate of SIDS in Tasmania – which is second only to that of the Northern Territory. Coroner Olivia McTaggart (2008) made particular note of her concerns about the circumstances surrounding the deaths, stating that some of these may have been prevented if child protection and other health or service providers involved at the time had acted differently.

In his report of the investigation into the death of one of the infants who had died in 2006, Coroner Rod Chandler (2009) said he believed that the initial assessment and investigation of the infant’s circumstances and the priority classification assigned to the case were inadequate, and that placing the child on a list of unallocated cases was

37 _{This definition is a result of a pathology workshop in Victoria, attended by coroners and pathologists from all over}

Australia. The policy is available at:

http://www.phaa.net.au/documents/policy/20091028SuddenUnexpectedDeathinInfancyandSIDsPolicy.pdf

“effectively abandoning further investigation of the infant’s circumstances”, which would have revealed that the infant was a ‘a child at risk’ and in need of protection. Although the lack of resources (with the number of unallocated cases exceeding 700 during 2006) was acknowledged to have been a contributing factor, the tragic outcome for this infant and for a number of other infants and young children brings the

investigation, assessment and prioritisation practices and processes relating to neglect into question.

In the VCDRC’s (2000) review of child protection infant deaths in Victoria between 1995 and 1999, nine of the fourteen cases reviewed for analysis had been attributed to SIDS. The decision to widen the scope of analysis – which was aimed at improving the relationship between maternity and child protection services – to include all infant deaths, including the SIDS cases, was based on the determination that high risk factors for child abuse and neglect were present, and that these risk factors had required an early intervention response which they had not received (VCDRC 2000). The determination to include SIDS cases was also responding to the fact that while the campaign in the early 1990s had succeeded in dramatically reducing the number of SIDS deaths in the general population, the number of cases in the child protection population has not decreased over time (VCDRC 2000). The risk factors reported in the review included the young age of the mother, maternal substance abuse, chaotic and unstable lifestyles, and the increased medical or health risk of the infant; including, prematurity, low birth weight, medical conditions, drug dependency, failure to thrive and later signs of dehydration.

It is remarkable also that while many of the reports reveal a preparedness to raise the issue of systemic neglect and to blame individual professionals for their lack of judgement or failure to take appropriate action, there is no reference to the ongoing neglect experience for and of the infant or to the omissions of care on the part of parents or primary caregivers, who are notably absent in most of the reports, existing only in terms of ‘risk factors’ present at the time. Whatever the reasons, there exists a deep- seated misapprehension of neglect as less critical and serious than abuse in child protection practice and in medical, health and welfare practice generally (see, e.g. Horwath 2005a, 2007; Minty et al. 1994).

The Victorian Child Death Review Committee (VCDRC 2007, 2008) reports some quite different findings and concerns. The VCDRC (2007) reported that the deaths of 14 infants aged 0-3 years known to Child Protection were categorised as follows: 7 had ‘acquired/congenital illness’; 4 were ‘not known – pending coronial findings’; 2 were ‘accidental’, and 1 case of ‘SIDS’. Over the 11-year period from 1996 to 2006, there were 118 deaths of infants known to Child Protection: of these 44 were categorised as ‘acquired/congenital illness’, 26 as ‘SIDS’; 15 as ‘accidental’; 12 as ‘non-accidental trauma’; and 21 were classified as ‘not known’. A review of 13 child deaths between 2006 and 2007 carried out by the VCDRC found that five of the eight infants’ deaths were linked directly to prematurity and/or congenital conditions. The chairperson of the VCDRC notes in the Foreword that since “children born with complex care needs require a higher standard of parenting than is usual; the consequences of neglectful parenting are particularly serious for these children” (VCDRC 2007, p. iii). And again,

“the most significant feature of the families involved in child death reviews was the co- existence of a number of factors that are known to reduce parenting capacity”, including family violence, parental substance abuse and parental mental illness (VCDRC 2007, p.

x).

Although ‘neglect’ is not included as a classifiable cause of death in the annual reports or reviews of paediatric deaths in Tasmania or Victoria, while abuse is, chronic neglect is acknowledged by the VCDRC to have been significant in the lives, if not the deaths, of many of the infants and young children who died. The VCDRC (2007) had

commissioned the Child Death Group Analysis: Effective Responses to Chronic Neglect

(2006) prior to releasing the findings, which they considered to be relevant as well as “valuable and insightful” (p. xiii). As the Commissioner at the time observed in his

introduction to the Child Death Group Analysis, the lives of the children who died

“were characterised by an accumulation of harms associated with chronic neglect” (Victorian Child Safety Commissioner, VCDRC 2006, p. v). The aim of the analysis

was “to contribute to the discussion regarding chronic neglect and cumulative harm and ensure that learning arising from a small group of child deaths is used to shape future policy and practice” (p. iii).

With the problem of maternal substance abuse worsening in recent years, there is a growing awareness of the need for further and more open discussion in the largely

unexplored area of prenatal neglect as well as infant neglect, especially because of this largely un-named association with infant mortality. Legal and illegal substance use in pregnancy is known to increase the likelihood of prematurity, low birth weight, neonatal abstinence syndrome (NAS), foetal alcohol spectrum disorders (FASD), abnormal foetal development and growth, and attachment problems (Carmichael et al. 2001; Jacobson & Jacobson 2001). It is an incongruous situation that a proportion of infants who are born with extra care needs and require higher than normal standard of care are the least likely to receive it. Infants who are born with conditions such as NAS can be very difficult to care for and to bond with – they are often inconsolable, they don’t like to be touched, are difficult to settle, and have a typical high-pitched scream – they require the type of care that parents who have a substance dependency and/or mental health problem are least likely to be able to provide. Affective, sensitive, responsive, linguistically rich and protective parental care and nurture are vital to children’s survival, growth and

psychological development and wellbeing (WHO 2004) – children are perceived by the World Health Organisation to have a right to this kind of care. Parents with the

increasingly common problem(s) of chronic substance abuse, mental health disorder or significant intellectual deficits, particularly in combination, are less likely to be able to meet those needs without intervention and support.

More specialised assessments based on developmental needs and intervention that retains a focus on the infant is lacking for this highly vulnerable group. The principles of minimal intervention and family preservation built into Australian child protection legislation, and the shift towards a ‘prevention and support’ approach has led to some criticism and concern about the safety of vulnerable infants in particular being left in neglectful and highly risky situations a (Goddard & Tucci 2008; Sammut & O’Brien 2009). This type approach involves an inordinate amount of trust in parents’ stated willingness to engage in rehabilitation and support programs in a timely fashion, when their ability to follow through and maintain the changes is often limited due to the complex nature of the most of the parental problems.

As Cash and Wilke (2003) point out, “the central feature of substance dependence is a combination of physiological, cognitive, and behavioural indicators that signal an

inability to control the use of alcohol or other drugs, particularly a persistence of use in

Psychiatric Association [APA] 1994)” (p. 394; emphasis added). The high rate of co- morbidity among those who mis-use substances – with affective disorders being the most common for women – means that there is no quick fix for substance dependence (Cash & Wilke 2003). It is hardly surprising to learn that a recent review of the effectiveness of intervention programs in the US provided ‘limited evidence’ that the programs work (Goddard 2009; Twomey et al. 2010).

In NSW child death review teams do cite neglect as a cause of death and distinguish between two types of neglect fatalities: a) those involving ‘supervisory neglect’ in critical incident or accident deaths, such as accidental drowning, gun accidents, choking, ingesting pills or as a result of house fires, are classified as ‘supervisory neglect’; and b) those involving ‘chronic neglect’ due to preventable issues such as malnutrition, starvation and dehydration (DoCS 2009, p. 9). Reviews of children’s deaths in NSW, like those conducted elsewhere, have highlighted the fatal

consequences of neglect and the importance of gaining a better understanding of the