INQUEST INTO THE DEATH OF
CHLOE LEE VALENTINE
Finding of Inquest – Cause of Death
Table of Contents
Finding of Inquest – Circumstances of Death
Finding Recommendations
An enlightened truth, and the bedrock of sound child protection, is that childhood is fleeting.
This time of life must be optimised for children’s sake, and for society’s good, because bad early
experiences have deleterious, life-long consequences. Because today’s child is tomorrow’s citizen,
modern nations place a premium on the care, education and socialisation of children. That adults
have a duty to nurture and not damage, disturb and distress children is a universal aspiration
shared by all civilised peoples. That Australians allow this social norm to be transgressed in our
rich and prosperous country is what’s so shocking about the harm done under the rubric of child
protection. The wrongs hereby perpetrated are of biblical proportions; doubly wicked are those who
protest otherwise but must know, in their hearts, minds and consciences, that what they say is false.1
Inquest conducted by Mr Mark Johns, State Coroner, South Australia
1
Do Not Damage and Disturb: On Child Protection Failures and the Pressure on Out-of-Home Care in Australia (2011)
Sammut, Jeremy – ISBN 9781864322064 http://www.cis.org.au/images/stories/policy-monographs/pm-122.pdf, page 21
CORONERS ACT, 2003
SOUTH AUSTRALIA
FINDING OF INQUEST
An Inquest taken on behalf of our Sovereign Lady the Queen at
Adelaide in the State of South Australia, on the 14th day of August 2014, the 4th, 22nd, 23rd,
24th, 25th, 26th, 29th and 30th days of September 2014, the 1st, 2nd, 3rd and 16th days of October
2014, the 1st, 2nd, 3rd, 4th, 5th, 8th, 10th, 11th, 12th and 15th days of December 2014, the 17th,
18th, 19th, 20th, 23rd, 24th and 27th days of February 2015 and the 9th day of April 2015, by the
Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into
the death of Chloe Lee Valentine.
The said Court finds that Chloe Lee Valentine aged 4 years, late of 18
Wilmot Street, Ingle Farm, South Australia died at the Women’s and Children’s Hospital, 72
King William Road, North Adelaide, South Australia on the 20th day of January 2012 as a
result of closed head injury with contributing extensive subcutaneous and intramuscular
haemorrhage.
INQUEST INTO THE DEATH OF CHLOE LEE VALENTINE
FINDING OF THE STATE CORONER
TABLE OF CONTENTS
1. Introduction and cause of death …………………………………………………………………………1
2. The events of mid January 2012…………………………………………………………………………2
3. Reason for Inquest …………………………………………………………………………………………….3
4. Chloe’s Families SA history ……………………………………………………………………………….3
4.2. The evidence of Trisha Foord, Kate Wallis, Krystal Benyk and Nicky
Behsmann………………………………………………………………………………………………..4
4.21. Ashlee obtains supported accommodation services from the Salvation
Army ………………………………………………………………………………………………………9
4.27. Families SA involvement with Ashlee and Chloe between Chloe’s birth
(July 2007) and October 2007 ………………………………………………………………….11
4.44. Strong Families Safe Babies team become involved……………………………………18
4.67. Amy Kidner, Strong Families Safe Babies, February 2008 to July 2008………..28
4.75. Closure of Strong Families Safe Babies file……………………………………………….32
4.83. 11 November 2008 to 17 November 2008 – period of chaos for Ashlee
and crisis for Chloe…………………………………………………………………………………34
4.94. The Port Youth Accommodation housing at Taperoo………………………………….40
4.115. Elizabeth Daniel……………………………………………………………………………………..52
4.119. Janelle Morris ………………………………………………………………………………………..53
4.136. Aftermath of Ashlee’s eviction from Louise Place – an overview…………………61
4.142. Families SA actions in 2010-2011…………………………………………………………….63
4.169. The evidence of Belinda Valentine……………………………………………………………71
5. Conflict of interest……………………………………………………………………………………………83
6. Families SA – workload issues and resources ……………………………………………………83
7. The perspective of the external agencies dealing with Ashlee – a radically
different perception …………………………………………………………………………………………86
7.3. Vicky Lachlan………………………………………………………………………………………..86
7.15. Cassandra Fick……………………………………………………………………………………….89
7.23. Joy Rann ……………………………………………………………………………………………….92
8. Emeritus Professor Freda Briggs – the content of the social work
undergraduate degree course …………………………………………………………………………..98
9. Anthony Kemp – former Director, Practice Development Families SA – an
overview of Families SA culture and practice……………………………………………………99
10. An analysis of the Children’s Protection Act 1993 …………………………………………..108
11. Adoption as an alternative placement option…………………………………………………..113
12. Power of investigation…………………………………………………………………………………….117
13. Divergences between the practices of Families SA and the terms of the
Children’s Protection Act 1993 ………………………………………………………………………122
14. Income management………………………………………………………………………………………131
15. Family reunification……………………………………………………………………………………….141
16. Cumulative harm …………………………………………………………………………………………..142
17. Children are not possessions…………………………………………………………………………..143
18. Continuity of care ………………………………………………………………………………………….144
19. Note taking…………………………………………………………………………………………………….144
20. Ashlee Polkinghorne’s responsibility ………………………………………………………………145
21. Summary of key issues……………………………………………………………………………………146
22. Recommendations………………………………………………………………………………………….152
ANNEXURE 1 – Persons referred to in the Finding……………………………………………….157
ANNEXURE 2 – Intake Summary………………………………………………………………………….159
ANNEXURE 3 – Accommodation Summary…………………………………………………………..161
1
1. Introduction and cause of death
1.1. Chloe Lee Valentine died on 20 January 2012. She was 4 years and 5 months old at
the date of her death. A post-mortem examination was conducted by forensic
pathologist, Dr Karen Heath, who provided a report2 giving the cause of death as
‘closed head injury with possible contributing factor extensive subcutaneous and
intramuscular haemorrhage’, and I so find.
1.2. Dr Heath said it was not possible to determine from the neuropathological findings
whether the head injury observed was a result of one episode of trauma or the
cumulative effect of several episodes of head injury. She said that other findings at
autopsy included extensive bruising of the scalp and face, back, chest, abdomen and
upper and lower limbs. She said that in particular there was extensive subcutaneous
and intramuscular bruising of the lower back, buttocks and thighs. It was this bruising
that was described as a possible contributing factor to the cause of death, namely
extensive subcutaneous and intramuscular haemorrhage. Dr Heath explained that a
bruise or intramuscular haemorrhage occurs as a result of a blunt trauma to the tissue.
She described in her evidence what she called a ‘confluent area of bruising’ which is
actually a large number of bruises that had all merged together into one bruise so that
she could not tell where one bruise finished and one started. She said the bruising
was not only in the skin and the fat underneath the skin, but was also in the muscles,
particularly of the buttocks and thighs. She said that there are layers of muscles in
those areas which sit one on top of the other. She said that when there is extensive
bruising blood can collect between those layers of muscle. She said that during
Chloe’s post-mortem examination she looked at the muscles in those areas and there
was a large amount of blood collected between those layers such that during the
dissection the blood squirted out under pressure rather than just oozing out or
remaining within the tissues. To Dr Heath this indicated that there had been a large
amount of blood contained within the muscle and the layers between the muscle and
that it had built up to a certain amount of pressure. She said that in cases where there
is extensive bruising and bleeding it has been documented that the severe bruising can
cause enough blood loss to cause death. It is for that reason that she described it as a
possible contributing factor to death in this case.
2
Exhibit C100
2
1.3. The means by which the bleeding contributes to death is of course a loss of blood
volume which further decreased the amount of blood that was available to supply
oxygen to the brain, thus starving the brain of more oxygen than was already
occurring from the swollen condition of the brain. Dr Heath was unable to attribute
how much each of those process contributed to death but considered that the head
injury was the predominant cause with a possible contribution from the blood loss
from bruising3. Dr Heath said she had never seen this degree of bruising in a child
before in her experience as a forensic pathologist and had only ever seen it once in an
adult4.
2. The events of mid January 2012
2.1. In mid January 2012 Chloe was living in a house at Ingle Farm with her mother
Ashlee Polkinghorne and Ashlee’s partner of the time, Benjamin McPartland. Ashlee
Polkinghorne and McPartland had purchased a 50cc dirt bike for Chloe. The bike was
far too big for her and she could barely touch the ground. She weighed 17 kilograms
at the time of her death but the bike weighed over 50 kilograms. Nevertheless,
McPartland repeatedly put Chloe on the bike despite her being unable to stop the bike
without falling off it to the ground. Ashlee Polkinghorne filmed these episodes using
her mobile phone. The footage shows McPartland putting her back on the bike and,
to use the words of the sentencing judge, Justice Kelly, ‘virtually throwing Chloe
back on the bike after she had fallen off’. This pattern of conduct started on Tuesday,
17 January 2012. It continued until Thursday, 19 January 2012 on and off. On that
day, certainly prior to 3:39pm, Chloe was rendered unconscious. By 3:39pm on that
Thursday either Ashlee Polkinghorne or McPartland were conducting internet
searches looking for advice on what to do with an unconscious person. However,
they failed to obtain any medical treatment for Chloe until 11:58pm on Thursday, 19
January 2012 after Chloe stopped breathing. Despite the fact that she was
unconscious they waited another 8½ hours before making the ambulance call. By
their own admission, during that intervening period they occupied themselves by
using Facebook, doing some internet banking, searching the internet as to what to do
when a person was rendered unconscious, and smoked cannabis.
3
Transcript, page 84
4
Transcript, page 84
3
2.2. The sentencing judge found that the conduct of repeatedly placing Chloe on the
motorbike and the failure to act by obtaining medical assistance for her once she was
unconscious amounted to a very serious example of the crime of manslaughter by
criminal neglect. McPartland had pleaded guilty to that crime approximately a month
before trial. Ashlee Polkinghorne did not plead guilty until the third day of the trial
after unsuccessful voir dire arguments about the admission of evidence. McPartland
was given a head sentence of 7 years with a non-parole period of 4 years and 2
months, and Ashlee Polkinghorne was sentenced to a head sentence of 8 years with a
non-parole period of 4 years and 9 months.
3. Reason for Inquest
3.1. The criminal offending of Ashlee Polkinghorne and McPartland were dealt with in the
appropriate forum. The Inquest did not focus on that period in January 2012. Instead,
the Inquest focussed on the nearly 4½ years of Chloe’s life leading up to those terrible
events in January 2012. The conduct of Ashlee Polkinghorne and McPartland in
relation to Chloe and the motorbike speaks for itself. One particularly chilling aspect
of it was that Ashlee Polkinghorne could be heard in the video showing Chloe’s
torment to be laughing at the child and her efforts to ride and maintain control of the
motorbike.
3.2. That complete failure to show the love and care that is to be expected of a mother
towards a child did not come out of nowhere. There had been many previous warning
signs that Ashlee Polkinghorne was unfit to be Chloe’s mother and guardian. The
warning signs had been made known to the child protection authority in this State
which is known as Families SA and is a part of the Department for Education and
Child Development. I refer to it in this finding simply as Families SA, except where
it is necessary to give it its formal title.
4. Chloe’s Families SA history
4.1. In this part of the finding I propose to describe through the evidence of a number of
different witnesses the many interactions between Families SA and Ashlee
Polkinghorne in relation to Chloe. Unfortunately this methodology will result in me
referring to the same incident through the eyes of a number of different witnesses,
however, I consider that to be the most convenient way of dealing with the matter.
4
4.2. The evidence of Trisha Foord, Kate Wallis, Krystal Benyk and Nicky Behsmann
Kate Wallis, Krystal Benyk and Nicky Behsmann were young women who were
friends of Ashlee Polkinghorne. Trish Foord was the mother of Kate Wallis and had
some involvement with Ashlee and Chloe by virtue not only of her daughter’s
friendship with Ashlee, but because of her daughter’s relationship with Ashlee’s
brother, Jake. Trisha Foord made notifications to the Child Abuse Report Line
(CARL). She said that her daughter Kate was living with Ashlee’s brother Jake and
Ashlee at the home of Alan Polkinghorne in 2006. At that time Ashlee was not
attending school. Ms Foord said that Mr Polkinghorne told Ashlee, Kate and Jake
that they had to leave his property. Ashlee had a boyfriend by the name of Thomas
Lagden to whom she became pregnant. She was couch surfing before obtaining a unit
provided by the Salvation Army. Ms Foord said that during Ashlee’s pregnancy she
saw her to be dirty, smelly and unhygienic and she had heard that Ashlee was taking
drugs and drinking. She was aware that Ashlee was not obtaining proper antenatal
medical treatment and Ms Foord was concerned about the baby. As a result of this
Ms Foord contacted the CARL and raised these matters, including Ashlee’s
involvement in a fight in which Mr Lagden was a participant.
4.3. Ms Foord said that once Families SA became involved and workers were visiting
Ashlee’s unit to check on Chloe she was aware that Ashlee was cleaning the premises
in preparation for their visits. She was concerned that Ashlee was deceiving the
workers.
4.4. Ms Foord became aware of a telephone call received by her daughter, Kate, from
Ashlee in the middle of the night when Ashlee was recorded by Kate as admitting that
she was high on drugs and was a better carer for Chloe when under the influence of
drugs. Ms Foord referred to an occasion when Chloe came to her house and she noted
that she was behind in her development.
4.5. Kate Wallis was Trish Foord’s daughter. She was in a relationship with Jake who was
Ashlee’s brother. Ms Wallis said that Ashlee’s unit with the Salvation Army was
dirty, smelly and unhygienic and that Chloe was always in a bouncer by herself. She
was not dressed appropriately. Ms Wallis referred to the telephone call from Ashlee
late at night. She said that Ashlee was talking really quickly and sounded ‘weird’.
Ashlee admitted that she was high and talked about how much money she was
spending on drugs. She made it plain that Chloe was present while she was taking
5
these drugs. Ms Wallis recorded some of the conversation5. The recording is that of a
highly excitable, irrational, foolish and almost hysterical teenager boasting about her
drug taking behaviour. Shockingly, she suggests that she is a better mother to Chloe
when taking drugs.
4.6. Ms Wallis said that she and Jake took the recording to the Families SA Modbury
office and met with two ladies. She played the recording for them. It was Ms Wallis’
understanding that Ashlee later found out about this report. However, there was a
subsequent report by Ms Wallis to CARL in which she expressed concern about
Chloe’s lack of development and domestic violence against Ashlee by her then
partner. Ms Wallis said that Ashlee found out about this report that she made to
CARL and after that Ms Wallis received threatening telephone calls in the early hours
of the morning including one from Ashlee threatening violence6. She said that she did
not see Ashlee or Chloe after that7.
4.7. Krystal Benyk met Ashlee Polkinghorne when they were working together at
McDonalds. Ms Benyk was two years older than Ashlee. When Ashlee was pregnant
with Chloe she asked Ms Benyk to be Chloe’s Godmother and Ms Benyk accepted.
In her evidence she said she regarded it as an honour to have that role and to guide
Chloe through life8.
4.8. Ms Benyk had a lot to do with Ashlee and Chloe and said that Ashlee did not want to
be around Chloe at times. As a result Ms Benyk did the feeding, changing and
bathing of Chloe. She said that Ashlee would be out the front of the house with
friends while she was with Chloe. She said that the unit was filthy with bottles and
nappies lying on a sticky floor. She said that there were no parents around and that
people could visit and smoke and drink, including using cannabis. She said that she
felt like she was there to look after Chloe as no-one else would do so. She said that
she did not take the matter up with Ashlee because she was intimidated by Ashlee,
knowing that she would ‘go off’ at Ms Benyk if she raised the matter9. Ms Benyk
5
The recording was admitted as Exhibit C102a and the transcript of the recording as Exhibit C65q
6
Transcript, page 149
7
Transcript, page 149
8
Transcript, page 156
9
Transcript, page 161
6
gave the following telling evidence when she asked why she did not express concern
to Ashlee about what was going on at this time:
‘Because she’d just crack it with you. She’d go off at you and that was it, you weren’t
allowed to come over, you weren’t allowed to see Chloe, so it was like a little game with
Ashlee. I didn’t want to say anything because I didn’t want Chloe not to have anyone
there.’10
This evidence is very revealing. It is consistent with Ashlee’s use of Chloe as a
means to get her own way and manipulate others.
4.9. Ms Benyk said that when Chloe was approximately 10 months old she started having
Chloe stay with her overnight at Ashlee’s request so that she could go out. Ms Benyk
was happy to accommodate her. This would happen once a week or a fortnight. After
Chloe was a year old then she would stay with Ms Benyk for weekends and then for
weeks at a time. She said that when it was time for Chloe to go home she would
contact Ashlee, but Ashlee would not pick up her phone. The longest that Chloe was
left in Ms Benyk’s care was for a period of four or five weeks11. Ms Benyk gave
evidence of Ashlee’s association with numerous men who were violent towards her12
and said that Ashlee did not care about putting herself in danger, so she would not
care about putting her child in danger either.
4.10. Ms Benyk gave evidence of Chloe’s condition when she came to stay with her. She
said that she was usually dirty and that her clothes smelled of ‘pot’. Her hair was
dirty. Ms Benyk would not use Ashlee’s clothes for Chloe but kept clothes for her at
her own house. She said that Chloe had nappy rash all the time and her skin was red
raw and that it took weeks to get rid of it. Ms Benyk said that when Chloe was 3
years old she told Ms Benyk that she hated her mother13. She also said that Chloe
would become distressed at the prospect of returning to Ashlee14.
4.11. Ms Benyk gave evidence of an event that took place when Chloe was approximately
14 to 16 months old when Ms Benyk picked Chloe up from Ashlee and Chloe did not
look very well. Ashlee brushed it off as being related to the fact that Chloe had only
just woken up from nap. However, when Ms Benyk tried to give Chloe something to
10
Transcript, pages 161-162
11
Transcript, page 166
12
Transcript, page 166
13
Transcript, page 170
14
Transcript, page 170
7
eat she vomited and was continuously sick so Ms Benyk took her to the Women’s and
Children’s Hospital. Ms Benyk was unable to get in touch with Ashlee as her phone
did not answer. The staff diagnosed Chloe as being dehydrated with gastroenteritis
and she was put on a drip and kept overnight. Ms Benyk stayed with her during the
night. She said that she was unable to make contact with Ashlee until 2am or 3am
and then told her that Chloe was in the Women’s and Children’s Hospital. Ashlee
said that she was ‘off her face on drugs and wouldn’t be able to come to the hospital
because they’d kick her out’15. Ms Benyk said that Ashlee arrived at the hospital in
the mid afternoon of the following day with a social worker from Families SA. She
said that Chloe was discharged into Ashlee’s care.
4.12. Ms Benyk said that when she made reports to CARL she did not give her name
because she was scared that Ashlee would find out that she had made a report and
then she would not be able to see Chloe16.
4.13. Ms Benyk said that when Ashlee commenced her relationship with McPartland in
2011 Ms Benyk’s contact with Chloe decreased and ceased altogether. She was no
longer able to have Chloe stay with her overnight. Ms Benyk said the last time she
saw Chloe was in the early part of December 2011 when it was suggested that Chloe
and Ashlee might spend Christmas Eve with her. McPartland interrupted and said
‘no’. He said this forcefully and aggressively. They were sitting in the lounge room
talking and Chloe had come out of her bedroom and wanted to play and talk with
them. According to Ms Benyk, Ashlee and McPartland told her several times to go
back to her room and play but Chloe persisted in coming out again. McPartland took
her to her room and told her if she did not listen she would get soap put in her mouth.
Chloe came out a short time later and McPartland said ‘you’re not listening so you are
getting soap in your mouth’. He went into the kitchen and Ms Benyk saw him chop
up a cake of soap, breaking it into little flakes. He put them in the palm of his hand
and mixed them with water making soap. He walked up to Chloe’s bedroom. Ms
Benyk next heard Chloe screaming hysterically and McPartland was telling her ‘next
time you’ll listen’. Ms Benyk could hear Chloe was very distressed and could hear
her gagging. She said to Ashlee that she wanted to go in and get Chloe out of there
and Ashlee replied with words to the effect of ‘don’t you think I want to as well’.
15
Transcript, page 173
16
Transcript, page 176
8
However, Ms Benyk was too intimidated by McPartland and had heard that he could
be violent. McPartland came out and said words to the effect ‘the little bitch’17.
4.14. In another statement Ms Benyk referred to having visited the house at which
McPartland and Ashlee were living with Chloe. She saw that they had setup a camera
in Chloe’s room which was connected to the television in the lounge room. Chloe had
been put in her room and McPartland was watching her on the television and when
she would go for the door handle to come out of her room, McPartland would yell at
her telling her not to come out18. Ms Benyk told Ashlee that she considered that was
McPartland was doing to Chloe amounted to child abuse19. She said that Ashlee did
not respond. Ms Benyk was asked why she did not report these later occasions
involving McPartland to CARL. She said she did not do so:
‘Because I had given up on them … Well it was four and a half years of reporting and
they did nothing, so like you lose all faith in the system. Sorry.’ 20
4.15. Ms Nicky Behsmann was a friend of Ashlee and Ms Benyk. She said that Ashlee was
very neglectful of Chloe from the very beginning, leaving Chloe in front of the
television in her bassinette for long periods of time and always wearing vomit stained
clothes21. She said that Chloe never at any stage had what she needed when under
Ashlee’s care and was never looked after properly under Ashlee’s care. She said that
the only time Chloe was looked after properly was when she was in other people’s
care, such as Krystal Benyk and a lady called Joy Rann who will be referred to later22.
Ms Behsmann said that Ashlee was affected by drugs a lot of the time while in the
Salvation Army unit, consuming marijuana and methamphetamines23. She said the
house was always messy with food stuck on the couch, clothes everywhere and
generally unhygienic24.
4.16. Ms Behsmann said that she was involved with Ashlee and Chloe for most of Chloe’s
life. She considered that Chloe had a very delayed development because Ashlee
never spent time teaching her. She said Ashlee was ‘too busy looking for somewhere
17
Exhibit C103
18
Exhibit C103a
19
Transcript, page 179
20
Transcript, page 180
21
Transcript, page 187
22
Transcript, page 188
23
Transcript, page 189
24
Transcript, page 190
9
and someone to drop her off to so she could go out and have a good time herself’25.
She said that she did not think Ashlee enjoyed being a mother26.
4.17. Ms Behsmann said that when Ashlee and Chloe were living in Royal Park in 2011,
immediately before they moved in with McPartland, Chloe’s room was kept very
dark. Ashlee had put sheets up on the window so that the room was very dark and
that she would not open a window and let fresh air in due to the fact that she was
‘paranoid that neighbours might smell the marijuana and report her for her drug
use’27. Ms Behsmann gave evidence that Ashlee would call Chloe a selfish little cow
and sometimes would call her a little bitch28.
4.18. Tellingly, Ms Behsmann said:
‘For four and a half years things didn’t really change; she always lived in squalor and
mess, but as much as I loved Chloe and I wanted to be there I was raised differently and I
have different expectations of how I would like to live.’ 29
She said that Ashlee never had any time for Chloe because all she wanted to do was
get high30.
4.19. Ms Behsmann said that around this time she became aware that Ashlee was engaging
in prostitution. She did not know who was looking after Chloe while Ashlee was
engaged in this activity.
4.20. Ms Behsmann made reference to the episode involving the video monitoring of Chloe
in her bedroom and McPartland yelling at her not to come out of her room when she
looked as if she was going to do so31. Ms Behsmann also gave evidence of
McPartland being abusive to her in Chloe’s presence when they were all in the car
together and McPartland told her to ‘get the fuck out of the car’32.
4.21. Ashlee obtains supported accommodation services from the Salvation Army
Katie Lawson was the Salvation Army case manager who managed Ashlee
Polkinghorne’s case. Ashlee obtained accommodation through the Salvation Army
between June 2007 and May 2008. She moved into the accommodation shortly
25
Transcript, page 192
26
Transcript, page 192
27
Transcript, page 194
28
Transcript, pages 195-196
29
Transcript, page 198
30
Transcript, page 198
31
Transcript, page 205
32
Transcript, page 207
10
before Chloe’s birth which occurred in July 2007. The case summary in the Salvation
Army file33 says that Ashlee’s twelve month stay came to an end because her lease
was not renewed due to a number of neighbour complaints and a large amount of
rubbish built up in the property. Furthermore, Ashlee did not engage in support
services offered by the Salvation Army.
4.22. Ms Lawson gave evidence at the Inquest and said that at the beginning of Ashlee’s
stay in the unit provided by Salvation Army at Hope Valley, Ashlee was quite
engaging and grateful for the accommodation. Her evidence painted a picture of a
situation that gradually deteriorated until it became completely unacceptable from the
Salvation Army’s point of view. After Chloe was born Ms Lawson would often find
Chloe in the bassinet in front of the television when she went for her scheduled visits.
Ms Lawson said that Ashlee would often refuse to let her see certain things. In the
end the Salvation Army became aware that, contrary to Ashlee’s lease agreement,
Tom Lagden was living in the premises. Accordingly, a letter was sent reminding her
that she was in a supported accommodation house and that the terms did not allow her
to have another person staying with her34. At one point when Ms Lawson visited the
premises Lagden was present and was introduced to Ms Lawson as Ashlee’s brother
Jake. The deception was revealed when Ms Foord make contact with the Salvation
Army to alert them to what had occurred and that the person was not Jake, but was in
fact Lagden35. By October 2007 the property was noted to be very dirty.
4.23. On 19 September 200736 Ms Lawson attended a case conference with Families SA
workers, Megan Cheverton and Kelly Francou. At this meeting there was a
discussion about the increasing seriousness of the situation regarding Ashlee and
Chloe. In particular, the meeting discussed the report made by Kate Wallis of the
phone call with Ashlee that she had recorded where Ashlee was talking about taking
drugs while Chloe was in her care. The note records that following this meeting,
which I will discuss in further detail when I come to the evidence of Kelly Francou,
Ashlee’s case would be managed by the Strong Families Safe Babies program.
4.24. Ms Lawson said that by early January 2008 it appeared that the Strong Families Safe
Babies team were happy with Ashlee’s progress. By contrast, Ms Lawson said that
33
Exhibit C84
34
Exhibit C84, page 75
35
Exhibit C84, page 105
36
Exhibit C84, page 109
11
the Salvation Army were not happy with the state of the unit and Ashlee’s attitude to
their service.
4.25. On 18 March 2008 an episode occurred that foreshadowed the end of Ashlee’s
goodwill with the Salvation Army. Ms Lawson received advice that the rubbish at the
unit had increased and that there were actually rats living in the rubbish and that the
Salvation Army was being asked to take immediate action for the benefit of the other
tenants in the unit complex. As a result of this information Ms Lawson and her team
leader attended the unit. Ashlee was not home, however the property had been left
unlocked and Ms Lawson and her colleague entered the premises. They found the
house to be filthy with rubbish, dirty nappies, food scraps, empty cans and bottles of
alcohol all over the house and that the laundry was full of dirty clothes with bags of
kitchen rubbish on top of them. As a result of this they made contact with Nicholas
Ratsch who was then an employee of Families SA in the Strong Families Safe Babies
team who was then involved with Ashlee. The following day Ms Lawson made a
CARL notification about the state of the property and the impact on Chloe. Ms
Lawson explained that she made the CARL notification because she wanted Families
SA to consider whether Chloe should remain in Ashlee’s care37.
4.26. As a result of the state of the property the Salvation Army finally took steps for
Ashlee to be evicted and she left the property in May 2008 in a filthy condition
requiring the Salvation Army to engage professional cleaners. Ms Lawson’s last
contact with the Strong Families Safe Babies team was on 11 June 2008 when she
was told that from their point of view there was nothing to suggest that Chloe was not
being cared for appropriately38.
4.27. Families SA involvement with Ashlee and Chloe between Chloe’s birth (July 2007)
and October 2007
During this period Ashlee was living in the Salvation Army supported
accommodation at Hope Valley. Megan Cheverton was a social worker at the
Modbury Families SA office at that time. Ms Cheverton said that as at 22 August
2007 there were five notifications in relation to Chloe and they were from different
people39. Ashlee and Chloe’s case was assigned to Ms Cheverton. The concerns that
had been expressed in those notifications included an unborn child concern, a report
37
Transcript, page 279
38
Exhibit C84, page 119
39
Transcript, page 300
12
of Ashlee and Chloe being at Tea Tree Plaza when Chloe was only a few weeks old
and Chloe had not been recently fed. It was reported that Ashlee was spending a lot
of time during the day at the local train station meeting with her peers. It was
reported that during this period Ashlee had informed a notifier that she had had a
binge of smoking ‘speed’ through a light globe for four days40 and that she looks after
Chloe better when she is taking speed41. Another report was to the effect that Ashlee
told Lagden to keep some speed that he was given so they could use it later on.
Reference is also made to Ashlee saying to Chloe ‘Ssh you bitch’ shortly after
Chloe’s birth. There is a report of Ashlee holding Chloe without proper support for
her head and putting her in the pram with a bottle propped up with a blanket. Chloe
was reported to have dried milk on her face, sleep in her eyes, dirty nails and a red
line in the crease of her neck. There was also a report that Ashlee was spending about
$300 per week on methamphetamines and was giving Chloe tap water to drink
because she could not be bothered making formula. The case was assigned to
Ms Cheverton on or about 22 August 2007. Ms Cheverton and another worker,
Leanne Sowerby, attended Ashlee’s unit at Hope Valley on an unannounced visit on
23 August 200742. Ashlee presented as hostile. The workers found the house to be in
a mess with a stale smell43. They put the drug allegations to Ashlee and she denied
them44. Ms Cheverton said that at that stage she was sceptical as to whether Ashlee
was telling the truth. She reported to her supervisor, Kelly Francou, on 24 August
2007 and it was agreed that Ms Cheverton would continue to work the case and work
with Ashlee and the other services that were already involved to monitor Chloe’s
safety45.
4.28. In response to another notification on 3 September 2007 from Child and Youth
Health, Ms Cheverton made another home visit. The notification was to the effect
that Ashlee’s unit was extremely messy and there was rubbish and dirty nappies on
the floor. Ashlee was not cooperating with the service. As a result of that concern
being expressed the workers attended Ashlee’s home. The note that they made of that
attendance46 was to the effect that they attended at the unit and knocked on the door
several times. A male voice from inside the unit called out ‘who is it?’ and then went
40
Transcript, page 301
41
Transcript, page 301
42
Transcript, page 305
43
Transcript, page 312
44
Transcript, page 312
45
Transcript, page 317
46
Exhibit C67, page 259 and Transcript, page 320
13
on to say that Ashlee was out with her mother and had Chloe with her. The male did
not open the door or identify himself and Ms Cheverton and Ms Sowerby left the
premises.
4.29. Ms Cheverton in her evidence said that a response of that kind is a common
experience when Families SA knock on the door.
4.30. Ms Cheverton said they returned to the office and then called Ashlee’s mother,
Belinda Valentine, to establish whether Ashlee was with her. She confirmed that
Ashlee was not with her and that they had had a fight a few days beforehand. Then,
later that afternoon, Ms Cheverton received a telephone call from Ms Wallis who
informed her that Ashlee had been at home while she was knocking on the door and
had no intention of answering the door to either Families SA or the Salvation Army47.
As a result of this Ms Cheverton and Ms Sowerby went straight back to Ashlee’s unit
and knocked on the door. This time Ashlee answered the door and appeared to be
expecting them. Ms Cheverton said that when they arrived there were obvious signs
that cleaning had been taking place and the bottle steriliser was operating48. However,
they briefly glimpsed at the bathroom and noted it to be unhygienic and noted that
there was a knife in the vanity area49. They noted on the file that Ashlee and the parts
of the home they were able to see presented very well on this occasion and ‘she is
very good at lying and hiding things and tells workers what they want to hear’50.
4.31. Indeed, this is a classic example of Ashlee’s manipulative behaviour. Unfortunately
this pattern was to continue for the next four years or so of Chloe’s life.
4.32. 6 September 2007 was the day on which Ms Wallis contacted Families SA and spoke
to Ms Cheverton to inform her that Ms Wallis was in possession of a recording of
Ashlee boasting about taking drugs and her ability to ‘look after’ Chloe while she was
on drugs. Ms Cheverton arranged with Ms Wallis to bring the recording in the
following day. As Ms Wallis had already said in her evidence, she did indeed bring
the recording into the Modbury office and it was played to Ms Cheverton on or about
7 September 2007. The tape makes harrowing listening. It is a rambling call from a
person who is obviously drug affected. It is impossible in this finding to convey the
47
Transcript, page 323
48
Transcript, page 325
49
Transcript, page 326
50
Transcript, page 327
14
impression one gains from listening to the tape. The conversation includes references
to Chloe and I will quote the most pertinent of them:
‘I look after her better (inaudible) or Krystal reckons I look after her better when I’m
fuckin like, when I’m on gear cos, I fuckin like, I don’t sort of like tense (inaudible) cos,
when I fuckin feed her right. I’ve got into this thing right. She doesn’t actually have to
go to sleep in anyone’s arms.’ 51
And as follows:
‘Alright and then now so, yeah and now it’s just easy cos, I can get drunk and do all that
kind of crap. Because all I have to do is if I was too drunk. I’d just put the bottle like.
I’d leave her in her rocker and put the bottle in her mouth instead of me holding it.’ 52
4.33. As a result of listening to this tape Ms Cheverton alerted her supervisor, Kelly
Francou, because she now had clear confirmation that Ashlee was in fact using drugs
while caring for Chloe. She said that this ‘therefore obviously increased our sense of
risk for Chloe’s safety’. From that moment Families SA had knowledge that obliged
it to make an application to the Youth Court under section 20(2) of the Children’s
Protection Act 1993. However, no such application was made. That is not surprising
in view of the evidence to which I will refer later given by Mr Harrison in relation to
section 20(2).
4.34. Ms Cheverton was not present when Ashlee Polkinghorne was asked to attend the
office and the tape was played to her. Ms Cheverton was away that day but became
aware that Ashlee did, after the tape was played, finally admit to drug use. Ms
Cheverton said that following this incident a decision was made that the case would
be referred to the Strong Families Safe Babies team and that this would occur in
approximately three weeks at the beginning of October 200753. Ms Cheverton agreed
that Ashlee should have been referred for drug and alcohol counselling at that time54.
I note that the best way to achieve that outcome would have been an application to the
Youth Court under section 20(2) of the Act. Once again I note that that did not
happen.
4.35. Kelly Francou gave evidence at the Inquest. She was the supervisor in the Modbury
office of Families SA who supervised Ms Cheverton and Ms Sowerby in relation to
51
Exhibit C65q, page 4
52
Exhibit C65q, page 5
53
Transcript, page 335
54
Transcript, page 338
15
Chloe and Ashlee’s case. Ms Francou gave evidence particularly about the occasion
when Ashlee was asked to attend at Families SA on 7 September 2007 to be
confronted with the tape recording. Ms Francou said she took the recording
extremely seriously55 and she described it as:
‘The turning point in the case for me to be able to do something.’ 56
That particular passage of evidence is very telling. I do agree with Ms Francou that
this episode represented a turning point in the sense that it presented an opportunity to
intervene in a way that might have changed the outcome. However, the opportunity
was in my view not taken.
4.36. Ms Francou said that when Ashlee came in her memory of the meeting was that
Ashlee was ‘a terrified kid, a 16-year-old, with a baby trying to manage talking to the
supervisor and the senior prac’57.
4.37. That passage of evidence demonstrates that Ms Francou was entirely misled by
Ashlee. Ashlee may have presented for that moment as a terrified 16 year old.
However, the reality was that she was quite worldly, perfectly capable of deceiving
social workers who knocked at her door and then receiving them in her home hours
later after she is proven to have deceived them and unashamedly showing them
around the house as if nothing had occurred earlier in the day. I think that Ms
Francou completely misread the situation and somehow believed that Ashlee was
actually intimidated by Ms Francou’s seniority. The fact is that Ashlee was unlikely
to understand what Ms Francou’s position was in the hierarchy of Families SA. I very
much doubt that she was intimidated at all. This was almost certainly another
example of Ashlee being manipulative and deceitful.
4.38. This is borne out by the fact that even on Ms Francou’s account of the event, Ashlee
was given an opportunity to admit to drug use and informed that if she was honest
about it she would be in a better position. Despite this offer, Ashlee kept denying any
drug use and it was only after she was finally played the tape that a crack began to
appear in her armour. Even then she initially denied that the tape was of her. At that
point Ms Francou suggested that they go to Gribbles and she provide a urine sample.
55
Transcript, page 578
56
Transcript, page 579
57
Transcript, page 581
16
At that point, according to Ms Francou, Ashlee ‘broke down’ and said that it was her
and asked them not to take her baby.
4.39. This is not the behaviour of a terrified ‘kid’. Instead, it is the behaviour of an
accomplished liar practised in deceit and manipulation. Ms Francou said that she then
suggested that the only acceptable way for Ashlee to proceed was with some form of
intense support from Families SA. She went on in the conversation to suggest that
Louise Place would be a good facility for Ashlee and Chloe. However, Ashlee was
well aware of Louise Place and knew that men were not allowed to stay there. She
was adamant that she would not be prepared to go to Louise Place because she was in
a relationship with Lagden and wished to maintain that relationship. Once again this
is indicative of an assertive person. Far from being a terrified kid, Ashlee was
prepared to stipulate what her requirements were, even when she was in this very
weak bargaining position. In my view this is a further indication that Ms Francou
completely misread the situation. I conclude that Ashlee was not at all intimidated by
this meeting and simply made only those concessions that she strictly had to make for
the purposes of keeping Families SA satisfied and avoiding, to the greatest extent she
possibly could, Families SA’s scrutiny. In any event, Ashlee agreed to cooperate with
Families SA58. At the end of the meeting Ms Francou actually thanked Ashlee for her
honesty. She explained that it was a very big thing for a 16 year old to admit what she
was doing and that was why she thanked Ashlee for her honesty. In my view it is
extraordinary that Ms Francou would take that step after Ashlee had been engaging in
blatant lies for the vast majority of the meeting and then had only finally reluctantly
admitted the truth when confronted with the tape. My impression is that far from this
being a meeting that was intimidating or confronting, instead the Families SA staff
took a ‘softly, softly’ approach with the result that any trepidation Ashlee might have
had at the beginning of the meeting would swiftly have dissolved. Certainly being
thanked for her ‘honesty’ would have emboldened her to engage in further lying and
manipulation later on.
4.40. Ms Francou gave evidence of a follow-up case conference which Ashlee was required
to attend. This occurred on 19 September 2007 at the Modbury District Centre. At
that case conference Ashlee came into the meeting and made an offer to submit
58
Transcript, pages 581-582
17
herself to regular drug testing to show she was committed to not using drugs. The
notes of that meeting record as follows:
‘Kelly, not wanting to take this punitive line at this stage, thanked Ashlee for her
commitment.’ 59
4.41. Ms Francou said she thought that Ashlee presented very well at the meeting and that it
was a ‘very frightening thing for her to come into that with all the professionals’. Ms
Francou said that she remembered Ashlee being very proud of the fact that she ‘hadn’t
used’60. I took Ms Francou to mean that Ashlee was proud of the fact that she had not
used illicit drugs in the period between 7 September 2007 and 19 September 2007
which was less than two weeks. Ms Francou’s position appeared to be that she
regarded this pride in a twelve day period of abstinence as something to be regarded
as a positive sign from Ashlee. In my view this demonstrates the tendency exhibited
by Ms Francou to be over optimistic. Twelve days of abstinence is hardly a major
achievement when the welfare of an infant of only three months is at stake.
4.42. It is interesting that Ashlee made the offer of submitting to urinalysis on a regular
basis at this second meeting. It should be remembered by that time she had had an
opportunity to reflect on the first meeting for some twelve days. As I have already
noted, at the first meeting she was thanked for her honesty and given good reason to
feel confident in her ability to bluff the Families SA workers thereafter. It should be
remembered that Ashlee was living with Lagden who had a considerable involvement
with the criminal justice system. He would have been well aware of the processes for
urinalysis and the opportunities that are afforded to users of that system to substitute
urine samples and so on. It is interesting to speculate whether Ashlee made this offer
following some discussion with Lagden. He would certainly have been in a position
to explain to her the ways in which urinalysis might be evaded.
4.43. Ms Francou in her evidence, as I have already said, demonstrated a tendency to be
over optimistic about Ashlee’s prospects. She suggested that the other agencies
shared her belief about the prospects of Ashlee’s commitment to abstaining from
drugs61. However, when it was pointed out to her that the representative from the
Child and Youth Health Service had said in the meeting that she had made ten
attempts to engage with Ashlee but only got to see her twice, and that the Salvation
59
Transcript, page 597
60
Transcript, page 597
61
Transcript, page 599
18
Army was far from happy with Ashlee’s performance as a tenant, she still seemed
unable to accept that she had an unrealistic idea of Ashlee’s true character. In my
opinion it is quite clear that Ms Francou adopted an unduly optimistic view of
Ashlee’s potential to change her behaviour.
4.44. Strong Families Safe Babies team become involved
The period from September 2007 until February 2008 during which Ashlee and Chloe
were residing at the Hope Valley Salvation Army unit was important for a number of
reasons. At this point Chloe was a newborn infant. Ashlee was her 16 year old
teenage mother who was, for the first time in her life, not only in charge of a
household, but responsible for the nurture and caring of the newborn infant, Chloe.
During this period the Strong Families Safe Babies section of Families SA took
responsibility for Ashlee and Chloe’s case. During this period their case was the
principal responsibility of Nicholas Ratsch who was then a senior social worker. At
the time of giving evidence he had been promoted to the position of principal social
worker in Families SA which is a very senior role and a role that provides consultancy
service and advice to workers in the field.
4.45. Mr Ratsch said that on 10 October 2007 he spoke to Ms Cheverton of the Modbury
office about Strong Families Safe Babies taking over Chloe’s case. Mr Ratsch then
understood that the Modbury office had undertaken an investigation and had
determined that Chloe was a high risk infant and the matter was being transferred to
Strong Families Safe Babies for family preservation work which he described as
trying to preserve the family unit62.
4.46. On 12 October 2007 Mr Ratsch undertook a joint home visit with Ms Cheverton. He
was introduced to Ashlee and she was told that he would be taking over her case.
This was his first meeting with Ashlee63. Mr Ratsch assessed Ashlee as being keen to
do anything she could to keep her child in her custody and he said that at that time she
was prepared to engage with his service64, although right from the very start there
were signs that Ashlee could be reluctant to cooperate because she told Mr Ratsch that
she was not keen on the frequency of the proposed home visiting which would be
approximately one to two visits per week65.
62
Transcript, page 456
63
Transcript, page 459
64
Transcript, page 461
65
Transcript, page 462
19
4.47. Mr Ratsch was well aware that the staff from the Modbury office had assessed Ashlee
as a convincing liar and he said that during his work with her he experienced the same
dishonesty. He gave as an example Ashlee telling him that she was in one place when
she was really somewhere else66.
4.48. Mr Ratsch’s next contact with Ashlee was on 19 October 2007 when he conducted a
home visit with Ms Libby Daniel who was the family support worker with whom he
was working. A family support worker is not a social worker, but a person who
assists social workers in carrying out their role. Mr Ratsch attempted to contact
Ashlee on 23 and 24 October 2007 with no success, but on 26 October 2007 they
attended a planned home visit67. They noted the unit to be untidy with a mattress on
the floor in the lounge where Ashlee slept because she was watching television until
late in the night. They also observed containers with leftover food on the couch68.
4.49. At a further home visit on 7 November 2007 Ashlee again enquired how long Strong
Families Safe Babies would remain involved with her and Chloe69. Once again she
was showing even from this early point her reluctance to participate in receiving
support to properly care for Chloe. The following day, 8 November 2007, Mr Ratsch
received a phone call from Dot Woods, an employee of the Child and Youth Health
Service (CYWHS) who had been visiting Ashlee since Chloe’s birth. Ms Woods
advised that her manager would like to convene a case conference to discuss future
CYWHS involvement. A meeting was set for 13 November 2007 and on that day Ms
Woods and another employee of CYWHS, Rosie Ranford, was present. Ms Ranford
indicated that she was concerned about Ashlee’s drug use and informed Mr Ratsch
that Ms Woods had visited the home and observed Ashlee to be substance affected
and unable to manage Chloe’s needs and needed to ‘palm off Chloe’s feeding to
Tom’70. Mr Ratsch was asked whether that was a serious concern. He said that it was
‘concerning that one parent is substance affected’71. When it was pointed out to him
that Ashlee had undertaken not to take any drugs at all72, Mr Ratsch appeared not to
be aware of that agreement and instead referred to a later agreement that was part of a
66
Transcript, page 464
67
Transcript, page 468
68
Transcript, page 468
69
Transcript, page 472
70
Transcript, page 473 and Exhibit C67, page 227
71
Transcript, page 473
72
This was a reference to Ashlee’s promise to Ms Francou on 7 September 2007 not to take any drugs at all
20
safety plan, to which reference will be made shortly. Mr Ratsch also was unable to
recall that Lagden was not in any event supposed to be living in the house73.
Following this meeting with CYWHS Mr Ratsch said they decided to put a ‘safety
plan’ in place74. He said that partaking in drugs ‘is not the preferred option’ but that if
it was something that Ashlee needed to do, that she needed to make appropriate care
arrangements75. He said ‘it’s called a safety plan’76.
4.50. It was pointed out to Mr Ratsch that Ashlee had previously been told that she was not
allowed to take drugs at all and it was suggested to him that the proposed safety plan
would be sending a mixed message and he acknowledged that ‘it could be seen that
way’77.
4.51. It was suggested to Mr Ratsch that this information about Ashlee’s drug use and her
need to ‘palm off feeding’ to Lagden should have resulted in a notification to CARL.
His immediate response was to ask whether the questioner meant should CYWHS
have made a notification? When it was suggested to him that he should have made a
notification he responded that as the allocated caseworker he was aware of it and able
to deal with it through his case management. He said that:
‘As I was the child protection worker already working with the case, I didn’t need to
make a notification for myself to have that information because I already had it.’ 78
Mr Ratsch was asked if it would have been prudent to make a notification so that
there is a further notification on the system. His response was:
‘I could have raised a notification which I would then have been investigating myself …
it wouldn’t have changed.’ 79
He acknowledged however that when information comes to a worker who is involved
with a case some workers will make a notification despite that fact80. In any event the
safety plan was duly prepared by Mr Ratsch and signed by Ashlee Polkinghorne and
Lagden on 23 November 200781.
73
Transcript, pages 473-474
74
Transcript, page 475
75
Transcript, page 475
76
Transcript, page 475
77
Transcript, page 475
78
Transcript, page 477
79
Transcript, page 481
80
Transcript, page 477
81
Exhibit C67, pages 308-309 Safety Plan
21
4.52. Mr Ratsch was asked a number of questions about the following paragraph in the
safety plan:
‘Ashlee and Tom agree that when they choose to consume alcohol or drugs, they will
arrange for a non-substance affected adult to provide care for Chloe – be responsible for
meeting Chloe’s needs.’ 82
It was suggested to Mr Ratsch that this almost amounts to an implicit condonation of
the consumption of alcohol or drugs but he did not agree83. Mr Ratsch acknowledged
that he drafted the safety plan84. When it was suggested to him that there was a major
difference between the terms of the agreement Ashlee had been required to give to Ms
Cheverton and Ms Francou a couple of months beforehand and the safety plan, he
responded ‘it could be perceived that way’85. Mr Ratsch’s reluctance to concede what
was obvious did not reflect very well on him as a witness. It is quite plain that there is
a fundamental difference between what Ms Francou had demanded of Ashlee and the
terms of the safety plan. Ms Francou had been adamant that Ashlee was to cease
consuming drugs and she had agreed to that. It will be recalled that she had even
offered to submit herself voluntarily to urinalysis testing. By contrast, Mr Ratsch’s
safety plan contained no prohibition at all and used the language of choice in relation
to Ashlee’s consumption of drugs. This is not a matter of a perceived difference, it is
quite obvious and he should have been prepared to concede it. Furthermore, he
should also have been prepared to concede that it was implicit in the safety plan that
Ashlee and Lagden will consume drugs or alcohol. That is the very purpose of the
paragraph. His reluctance to concede that is another example of his attitude as a
witness. In the end, he finally acknowledged that it would have been better to avoid
any form of condonation of drug use in a 16 year old in the hope that it might be
possible to get her to abstain from drugs completely86.
4.53. In any event, on the same day as the meeting took place with Ms Woods and Ms
Ranford from CYWHS, Mr Ratsch and Ms Daniel attended at Ashlee’s house and
observed the build-up of rubbish. It was planned to visit Ashlee the following
Monday to assist in tidying the house. Mr Ratsch was asked in his evidence whether
82
Exhibit C67, page 309
83
Transcript, page 482
84
Transcript, page 483
85
Transcript, page 484
86
Transcript, page 484
22
he perceived it as part of the role of a social worker at the Strong Families Safe
Babies team to help with waste removal and his response was in the affirmative87.
4.54. A further home visit took place on 26 November 2007 and again this was a planned
home visit. The house was noted to be clean and orderly. Once again Ashlee was
asking how much longer Strong Families Safe Babies would be involved. Mr Ratsch
said that this was a regular feature of conversations with Ashlee88.
4.55. The next significant event occurred on 30 November 2007 when Mr Ratsch received
information from a police officer, Detective Brevet Sergeant Rankin, who herself had
received information from Ms Trisha Foord about Ashlee and Chloe. Detective
Rankin said that information from Ms Foord was reliable. The information was that
Lagden had been involved in a fight with a person at Tea Tree Plaza the previous day
and that Ashlee had left Chloe in her pram to become involved in the fight with
Lagden. In addition to this Ms Foord raised a general concern about drug use within
the home. Mr Ratsch made a telephone call to the police officer, Detective Rankin,
however he did not make contact with Ms Foord. He conceded that he should have
done so but could not recall why he did not89. In relation to this episode Mr Ratsch
conceded that it would have been prudent for him to have notified the matter to
CARL90. It had taken a number of days for Mr Ratsch to make contact with Detective
Rankin. He said that there would have been little point in him attending at Ashlee’s
unit after his conversation with the police officer because the incident had taken place
several days prior by that stage and it did not suggest an immediate danger91.
However, he had not had any contact with Chloe or Ashlee for some days and
acknowledged that he did not know whether Chloe was safe or not92.
4.56. Mr Ratsch’s next home visit was on 10 December 2007 when he noted:
‘Still no overt signs of drug use. No indication of sores, track marks, substance affected
behaviour during workers’ visits, nor illicit substances or substance abuse paraphernalia.
This is a safety factor as it indicates that the parents have not ceased substance misuse,
that it has been reduced somewhat and that the parents are being responsible about
appropriately storing it.’ 93
87
Transcript, page 486
88
Transcript, page 497
89
Transcript, page 501
90
Transcript, page 501
91
Transcript, page 501
92
Transcript, page 502
93
Transcript, page 506
23
4.57. Then, on 12 December 2007, Mr Ratsch and Ms Daniel met with Carolyn Curtis (nee
Lockett), their supervisor at Strong Families Safe Babies for the purposes of preparing
a case consultation sheet. It is a matter of concern that the case consultation sheet
contains the following statement:
‘To date no service has sighted any evidence to suggest that either parent is using drugs
and the parents have not presented on any occasion as being under the influence.’ 94
Mr Ratsch acknowledged that Ms Curtis would not have known that piece of
information of her own knowledge and she must have got it from Mr Ratsch and Ms
Daniel at the case consultation meeting95. He acknowledged that the information was
wrong because such concerns had indeed been raised by CYWHS workers. Mr
Ratsch was unable to explain how this wrong information found its way into the
document96. Furthermore, there was nothing in the case consultation that reflected the
information that had been reported by the police officer who had conveyed Ms
Foord’s concerns. Mr Ratsch acknowledged that it did not appear from the notes that
he had informed his supervisor, Carolyn Curtis, of that information but said that he
believed he would have had ‘the conversation’ with her and that ‘there are many
conversations that were had between myself and my family support worker and the
supervisor which were not necessarily casenoted’97. This is an acknowledgement of
an issue that was apparent throughout this Inquest, namely that the casenotes failed to
record many pieces of information that ought to have been included in them. Mr
Ratsch acknowledged that when he observed things that potentially could have been
the subject of a notification, he foreclosed the possibility of abuse being concerned if
he did not make a notification himself. He acknowledged that people looking at the
file subsequently would not know what he had observed unless his record keeping
was meticulous and that he had acknowledged that he did not record everything that
had happened98.
4.58. Mr Ratsch undertook a further home visit on 10 January 2008 and on this occasion he
noted that there was a water bong used for cannabis smoking in the family home and
Lagden and Ashlee had said that it was Ashlee’s and that she occasionally smokes
cannabis99. The unit was also noted to be full of rubbish and car parts100.
94
Exhibit C67, page 206
95
Transcript, page 509
96
Transcript, page 509
97
Transcript, page 511
98
Transcript, page 542
99
Transcript, page 515
24
4.59. A further home visit took place on 21 February 2008 and on this occasion the house
was clean and tidy. The workers discussed Ashlee’s amphetamine use with her and
she claimed that it had no impact on her parenting101. Ashlee was very dismissive of
concerns about her amphetamine use and made jokes, smirked and rolled her eyes102.
Despite this clear evidence that Ashlee was engaging in amphetamine use, when
asked if he got that impression Mr Ratsch was only prepared to answer ‘possibly’103.
He was unable to say why Ashlee would have carried on in the way she did if she
were not using drugs104. In my opinion it is clear that she was and clear that Mr
Ratsch would have been aware of that, however he was not prepared to make that
concession in his evidence. This does not reflect well on him at all.
4.60. In late February 2008 Ms Lawson from the Salvation Army contacted Ms Daniel to
say that she had received a letter of complaint from a neighbour of Ashlee’s in the
unit complex. It raised the concerns that there were more than three males residing at
the property with Ashlee and Chloe, that police were frequently at the property, that
bikes and cars arrived at all hours of the night and that conversations about drugs and
drug use had been overheard with yelling and screaming at all hours of the night and
drunken youths loitering in the area of Ashlee’s unit. There was also an email from
Ms Lawson to Ms Daniel saying that Ashlee was not able to form sentences when Ms
Lawson spoke to her on the telephone105.
4.61. In response to the letter and information from Ms Daniel, Mr Ratsch set about
investigating the allegations. He contacted the police officer I have referred to earlier,
Detective Brevet Sergeant Rankin. He asked her about the allegation that there had
been a number of recent SAPOL visits. After some time he received a telephone call
from the police officer to inform him that there had not been any police attendances at
the house other than when police were looking for someone at that address106. This
appeared to be a source of some comfort to Mr Ratsch, although it would seem that
police attendances looking for a particular person at a particular address are hardly a
positive sign. On 11 March 2008 Mr Ratsch contacted Ms Lawson effectively to
make a case in support of Ashlee remaining in the unit as there was a real possibility
100
Transcript, pages 515-516
101
Transcript, page 517
102
Transcript, pages 517-518
103
Transcript, page 518
104
Transcript, page 518
105
Exhibit C67, page 183
106
Transcript, page 521
25
at that time that the Salvation Army would terminate the lease107. There is a reference
to a possibility that Chloe might stay in Bridgewater with Ashlee’s mother and Mr
Ratsch is noted as having ‘argued’ that this is not a great option, as Chloe was in a
critical attachment period and it could be traumatic and have detrimental
consequences for her to be separated from Ashlee at that time108. This is an indication
that Mr Ratsch was aware of a possibility that Ms Valentine might be able to care for
Chloe at this time, but that it would involve a separation from Ashlee. However, he
was opposed to the idea.
4.62. The next concerning event took place on 19 March 2008 when Ms Daniel received a
phone call from a person called Mary from the Salvation Army who said that she and
Ms Lawson had been out to a home visit at Ashlee’s house. They informed Ms
Daniel that the house was unlocked and no-one was at home and that she and Ms
Lawson had entered the unit and had observed the lounge to be untidy with rubbish
and several dirty nappies on the floor, piles of dirty clothes in the laundry with bags of
rubbish on top with ants crawling over everything, a queen size mattress in the back
room in an untidy state, the kitchen was untidy and there was a patched hole in the
wall near the front bedroom109. They had also received complaints from Housing SA
that rats had been seen on the premises110. Mr Ratsch was informed of this
information by Ms Daniel111. He then contacted Mary from the Salvation Army and
essentially confirmed what had already been said to Ms Daniel. He made the
following note:
‘*** Salvation Army, as the landlord, had no legal right to enter the home and were
effectively trespassing ***’ 112
He said that he made that entry for ‘further consideration’ because he was ‘concerned
that effectively the landlord had entered the house essentially unlawfully or at least
that’s what I believed at the time’113. That same day Mr Ratsch attended the premises
for an unannounced home visit. They observed some rubbish and a broken mirror in
the bathroom which Ashlee acknowledged had happened sometime before. They
noted that there was a hole in the wall which Ashlee said occurred when she fell over
107
Exhibit C67, page 174 and Transcript, page 522
108
Exhibit C67, page 174 and Transcript, page 523
109
Exhibit C67, page 164
110
Transcript, page 526
111
Transcript, page 527
112
Exhibit C67, page 163
113
Transcript, page 527
26
into the wall and ‘fell straight through it’. Ashlee and Lagden reported that they felt
the house had termites and that the walls ‘were weak’114. They assisted Ashlee to
remove the rubbish and clean up. They filled the boot of their car and the back seat
with rubbish bags and took them away. Mr Ratsch was asked what the hole in the
wall might actually have been caused by and responded that it was hard for him to
speculate. It was pointed out to him that as part of his job of investigating it is
important to speculate to determine how the holes might have got there and then to
carry out further investigations and enquiries. He said he ‘could’ speculate that there
had been some violence in the home or that it could have been caused by drunken
behaviour115. He took it no further than asking Ashlee and receiving a response that
she believed that there were termites in the home. However, he did not see any sign
of termite activity. It was suggested to him that this was just a silly claim and he
finally acknowledged that he suspected it was116.
4.63. It was at this point that Ms Lawson from the Salvation Army made a CARL
notification of her observations of the house when it was unattended that day. The
notification included information that numerous people frequent the house on a
regular basis, including people residing in the property who should not be, that people
were intoxicated and yelling and attracting police attention. She included the
information that there was a build-up of rubbish around the house and that when the
house was visited and found to be unlocked it was in an extremely untidy and
unhygienic state and was seen to have alcohol cans scattered, bags of rubbish, dirty
clothes, dirty nappies and so on. As a result of that notification Mr Ratsch conducted
a further home visit with Ashlee the following day, 20 March 2008. He informed her
of the notification. He noted that ‘Ashlee reported that she was feeling upset and
unmotivated because of the notion that someone had been inside her house and
notified on her’. He noted that ‘Ashlee reported that she felt unjustly treated by
Salvation Army’. Mr Ratsch made a further inquiry about the hole in the wall but
Ashlee maintained that she was not substance affected, presumably falling back on
her claim that the wall was ‘weak’. Ashlee denied that anyone else was residing in
114
Exhibit C67, page 163
115
Transcript, page 531
116
Transcript, page 522
27
the house. Mr Ratsch informed Ashlee that he would not be confirming abuse as a
result of the notification117.
4.64. Mr Ratsch was asked in his evidence whether he conveyed to Ashlee that it was his
opinion that it was inappropriate for the Salvation Army to enter her house and he
responded that he possibly did. In my opinion, from the tone of the notes, and from
Mr Ratsch’s evidence on this subject118, he almost certainly did express that opinion to
Ashlee. Mr Ratsch was asked what identifiable damage Ashlee suffered as a result of
this allegedly unlawful intrusion by the Salvation Army and he responded ‘nothing
really beyond the embarrassment of being caught out’119. He was then asked whether
he thought that it was in the public interest that she was caught out on this occasion or
not and he responded ‘you could argue it was in the public interest’120. He was then
asked:
‘Q. You could just argue that, is that right. Is that how you measure the welfare of a
child that it’s arguably in the public interest that it be exposed.
A. I believe that when children are in danger it needs to be addressed, yes.
Q. And surely that’s exactly what was achieved by the Salvation Army’s representative
entering the house.
A. Yes.’ 121
4.65. It was suggested to Mr Ratsch that it was foolish for him in dealing with Ashlee who
was uncooperative, and engaging in behaviour that was exposing her child to risk, to
do anything that might lessen her respect for authority. It was suggested that if
anything he would want her to have a respect for authority and not a greater contempt
for it than she already had. With this he agreed. He claimed that he encouraged his
‘clients’ to have respect for authority. However, he conceded that this philosophy did
not come through in this instance122. He conceded that he would look at it differently
now123.
4.66. This is a particularly concerning instance of Mr Ratsch going beyond merely
advocating for Chloe and Ashlee. In this instance he engaged in the foolhardy
behaviour of criticising another agency to Ashlee and, furthermore, suggesting that it
117
Exhibit C67, page 161
118
Transcript, pages 537-538
119
Transcript, page 538
120
Transcript, page 538
121
Transcript, page 538
122
Transcript, page 539
123
Transcript, page 539
28
had behaved in unlawful conduct and that she was right to feel unjustly treated by it.
However, that very conduct had exposed matters of concern in relation to Chloe that
would not otherwise have been uncovered. In my view it is extraordinary that an
employee of Families SA would adopt this kind of attitude. It is plain that the
Salvation Army was providing a service to Ashlee and a high level of support
themselves. She was refusing to engage with Ms Lawson, but the service was still
available should she choose to use it. She certainly had a roof over her head courtesy
of the Salvation Army. I would have thought that it would be in everyone’s interest
for Mr Ratsch to have been supportive of the Salvation Army in his dealings with
Ashlee, and not to have undermined the efforts made by the Salvation Army to check
on the conditions in the unit. It is quite clear that the Salvation Army workers were
not motivated by malice in any way in their decision to enter the property that day.
They reported that they had found the premises unlocked and they said they kept
calling out as they went in to see if anyone was there. They then made observations
which were extremely concerning and which had child protection ramifications. In
my opinion Mr Ratsch should not have in any way implied to Ashlee that the
Salvation Army employees’ actions were in anyway inappropriate. Doing that merely
served to embolden Ashlee further in her defiance of authority figures, including
Families SA itself.
4.67. Amy Kidner, Strong Families Safe Babies, February 2008 to July 2008
The narrative for this period is best told through the evidence of Amy Kidner. Ms
Kidner was a student social worker at that time who was undergoing her placement at
Families SA. She was placed with the Strong Families Safe Babies team and at the
beginning of her placement she was supervised briefly by Nicholas Ratsch. Later she
was supervised by Carolyn Curtis. She said that the Strong Families Safe Babies
team was intended to be a high risk infant program dealing with children under the
age of two years. I have mentioned that initially the senior social worker was
Nicholas Ratsch. Throughout Ms Kidner’s placement she also worked with Libby
Daniel, the family support worker124. Ms Kidner’s first meeting with Ashlee and
Chloe was at the Salvation Army Hope Valley unit on 18 February 2008 for a home
visit. On that occasion Ms Kidner said that Ashlee was friendly and open to them
being there and did not show any sign of hostility125. However there was some
124
Transcript, page 402
125
Transcript, page 405
29
rubbish outside the unit but she did not recall there being any particular concerns in
relation to Chloe.
4.68. By 16 April 2008 Ashlee was facing eviction from the Salvation Army unit. Ms
Kidner said that on 22 April 2008 she made seven telephone calls in relation to
storing furniture on behalf of Ashlee until she could find somewhere to live126. Ms
Kidner said that if Ashlee required help with obtaining furniture storage,
notwithstanding the fact that she had her own mobile phone, Ms Kidner would assist
with that. She did not regard it as odd then and does not regard it as odd now. She
said that it helped to build a rapport with Ashlee127.
4.69. A home visit made by Ms Daniel, of which Ms Kidner was aware but not present, on
29 April 2008 recorded that there was rubbish in every room of the house and clothes
on the floor and that a mattress on the floor was used for Ashlee and Chloe to sleep
on. The note of Ms Daniel on that occasion accords that Ashlee was asked to ‘think
about’ getting rid of the rubbish before Thursday when Ms Daniel would attend with
Ms Kidner to help clear the house before the final inspection128. On the following
Thursday Ms Kidner and Ms Daniel did indeed assist Ashlee to clean the unit129. Ms
Kidner saw nothing odd in cleaning Ashlee’s unit on her behalf on that occasion and
did not think it odd when giving evidence130. It is interesting to note that at about this
time the file shows a telephone call from Belinda Valentine in which she is noted as
saying that she wanted Ashlee to have a reality check because Ashlee did not take
responsibility131. Also, Ms Valentine said that Ashlee was not brought up to be messy
or dirty but that she chose not to care because she was taking drugs132. It is clear that
Ms Valentine was attempting to engage with Families SA and was wanting a firm line
to be taken with Ashlee. It is equally clear however that the workers were taking
what might be described as a ‘softly softly’ approach in assisting Ashlee with
activities that ought to have been Ashlee’s responsibility, for example, cleaning up her
own mess.
4.70. Ms Kidner said that on 15 May 2008 she took Ashlee, Lagden and Chloe to the
furniture storage facility to sign the storage agreement for the furniture. On this
126
Transcript, page 407
127
Transcript, page 408
128
Transcript, page 410
129
Transcript, page 410
130
Transcript, page 411
131
Transcript, page 411
132
Transcript, page 411
30
occasion she said that Ashlee appeared ‘very skinny, I observed that Ashlee’s hip,
shoulder and backbones were very visible in the clothes that Ashlee was wearing’133.
Ms Kidner acknowledged that this may have been a sign of drug use134. On another
occasion at about this time135 Ms Kidner went to considerable efforts to obtain
funding for taxi travel so that Ashlee could attend an open inspection because she was
at that stage homeless136. During this period Ms Kidner recorded taking Ashlee to real
estate agents each week so that she could apply for rental in a number of different
houses. Ashlee was asking Ms Kidner to do a lot of running around for her137. For a
period during this chapter in Chloe and Ashlee’s life of homelessness they did have
accommodation briefly at the home of Lagden’s mother138 however that was not a
long term option139.
4.71. On another occasion Ms Kidner took Ashlee to a visit at an organisation called JPET
for the purposes of attempting to find paid work for her. Ms Kidner then drove
Ashlee home to the place she was staying. However, Ashlee did not invite Ms Kidner
into the house and Ms Kidner was unable to sight Chloe. Ms Kidner had to sit outside
on the front porch having a conversation with Ashlee140.
4.72. Ms Kidner gave evidence that on 12 June 2008 she was concerned because Chloe had
not been sighted by a member of Families SA since 27 May 2008. On that occasion
when Ms Kidner attempted to arrange to see Chloe she was told by Ashlee that Chloe
was in the care of a friend and so therefore she could not see her. Ms Kidner asked if
Chloe would be available the following day and Ashlee replied by saying that she did
not know what she would be doing the following day. Ms Kidner accepted that
Ashlee was not being cooperative at that point and she gave evidence that she did not
feel that she had the skills at that time to assert herself with Ashlee141. Ms Kidner then
raised the matter with another senior social worker in the office, a Mr Frick, who then
himself attempted to make contact with Ashlee to arrange for Chloe to be sighted. Mr
Frick was no more successful because Ashlee refused to tell him the friend’s name
that Chloe was with or the address. Mr Frick made a note that Ashlee made a
133
Transcript, page 417
134
Transcript, page 418
135
21 May 2008
136
Transcript, pages 422-424
137
Transcript, page 427
138
Exhibit C71, page 94
139
Transcript, page 428
140
Transcript, page 432
141
Transcript, page 434
31
‘speech’ about how Strong Families Safe Babies thinks that Ashlee is a good mother
and is always praising her and therefore she does not need Families SA ‘looking over
her shoulder and parenting her and harassing her’142. Ms Kidner acknowledged that
Ashlee may have made these comments as a result of positive encouragement and
praise that she herself and others, presumably, had provided to Ashlee by way of
encouragement143. In any event, that day a further call was made by Mr Frick to
Ashlee to inform her that if Families SA were unable to sight Chloe that day he would
arrange for Crisis Care to visit her over the weekend. This prompted Ashlee to
provide an address for the workers to attend. The address is not noted in the file and
it is only possible to deduce from the note that the address was not that of Lagden’s
mother, but that of a friend144. The workers were not invited into the house on that
occasion and had to make do with sighting Chloe outside the house145. Ashlee
presented as difficult to engage and uncooperative146.
4.73. Ms Kidner said that on 20 June 2008 she attended at Ashlee’s house to pick her up to
take her for a JPET appointment but Ashlee was not home. The JPET supervisor
reported that she failed to attend the appointment147. Thereafter a number of attempts
were made to contact Ashlee by telephone but it was either switched off or her phone
was answered by a male, believed to be Lagden. Ms Kidner acknowledged that
during this period Ashlee was becoming more evasive148. Nevertheless, Ms Kidner
continued with her efforts to obtain accommodation and work for Ashlee, making
numerous phone calls. After several days of being unable to contact Ashlee the
workers attended at Lagden’s mother’s address where they were able to speak to
Lagden. He said that he was going to meet Ashlee at Tea Tree Plaza and they offered
him a lift to that location. On arrival at Tea Tree Plaza, Lagden saw Ashlee and
called out ‘FAYS workers’ and Ashlee appeared to be embarrassed by their
approach149. Ashlee was hostile and uncooperative. The workers agreed that they
would go away and see Ashlee the following Wednesday. At least on this occasion
they were able to sight Chloe. Ashlee refused to tell them where she was living at that
point150.
142
Transcript, page 435
143
Transcript, page 436
144
Transcript, page 440
145
Transcript, page 440
146
Transcript, pages 440-441
147
Transcript, page 442
148
Transcript, page 443
149
Transcript, page 444
150
Transcript, page 445
32
4.74. During this period Ms Kidner agreed that she was running around after Ashlee trying
to find her and that Ashlee had the upper hand151. In the middle of July 2008 Ms
Kidner’s placement at Strong Families Safe Babies ended and her involvement with
the case ceased.
4.75. Closure of Strong Families Safe Babies file
I have already mentioned that from 1 May 2008 when Ashlee was evicted from the
Hope Valley unit she and Chloe were effectively homeless, although they did spend a
portion of that period living with Lagden’s mother.
4.76. On 21 July 2008 Carolyn Curtis closed the Strong Families Safe Babies file. I will
deal with that event in more detail under her evidence. Despite the closure of the file
Ms Daniel was directed to keep working with Chloe and Ashlee152.
4.77. On 28 August 2008 there was a notification to CARL. The notifier was Senior
Constable Adrian Cox who was a police officer. He said that around August 2008 he
regularly patrolled Civic Park opposite Tea Tree Plaza. A number of people would
drink alcohol under the rotunda at that location and there were public order problems.
On 26 August 2008 he was on the afternoon shift. He and his partner spoke to a
person by the name of Bobby Edwards who had a child with him in a stroller. The
officers ascertained that the child was Chloe Valentine. Bobby Edwards was then 16
years old and said that he was looking after Chloe for Ashlee Polkinghorne, her
mother. Senior Constable Cox said that it was a cold evening. The officers spoke to
him and suggested that he take Chloe home due to the temperature and the time of
night. They then watched from their car as Bobby Edwards pushed Chloe in her
stroller towards where they believed Ashlee lived153. The following day, 27 August
2008, they again saw Bobby Edwards pushing Chloe in a pusher in the vicinity of Tea
Tree Plaza. They stopped to speak to him because it was the second night running
and as they were with him Ashlee appeared from the direction of the liquor store at
Tea Tree Plaza. The officers took Ashlee’s details as well as those of Chloe and
Bobby Edwards and decided that they would make a notification to CARL. Senior
Constable Cox was concerned at what he regarded to be ‘shabby parenting’154 because
he thought it was inappropriate for the child to be passed around in the company of
151
Transcript, page 446
152
Transcript, page 1004
153
Transcript, page 709
154
Transcript, page 711
33
people who were hanging around and causing various problems. As a result, Senior
Constable Cox made a CARL notification the following morning.
4.78. As a result of Senior Constable Cox’s notification an intake was raised. It went to
senior social worker Jennifer Warren at the Modbury office of Families SA. Ms
Warren gave evidence that she reviewed the notification and considered that it was
worthy of investigation but she recommended that it be closed with no action because
the office did not have the staffing capacity to investigate it155.
4.79. On 9 September 2008 Ms Daniel from Strong Families Safe Babies had a
conversation with Ashlee who told her that she was at that time trying to find a place
to sleep for the night. She confirmed that she had Chloe with her156.
4.80. On 24 September 2008 a notification was made to CARL. This notification was made
by Ms Trisha Foord. The concerns expressed by Ms Foord were that Chloe and her
mother had moved in with a man known to have an extensive criminal history
including drug charges. Ashlee was said to be drinking a lot of alcohol and using
whatever drugs she could get. Chloe had been sick and vomiting and was losing her
hair. Ashlee continued to be transient. This intake was considered by Ms Warren
who, once again, recommended that the intake be closed with no action. She said
there were no staff to deal with this notification157.
4.81. A further notification was made on 10 November 2008 reporting that the previous day
Ashlee was seen with Chloe at the park opposite Tea Tree Plaza where Ashlee was
drinking. Chloe was carrying around a can of beer and was drinking from it. Lagden
came through the park and Ashlee and Lagden had an argument and Ashlee hit him
and spat at him in Chloe’s presence. The notifier was a friend of Ashlee’s who
remained anonymous. The friend took the can of beer away from Chloe and
distracted her while her mother was fighting. They removed the caked on formula
from Chloe’s bottle and cautioned Ashlee on her parenting but Ashlee did not appear
to care about the concerns. The outcome of this notification was that a worker
discussed the matter with Ms Curtis who said that Strong Families Safe Babies were
still working with the mother and child and the mother was due to obtain
155
Transcript, page 631
156
Transcript, page 632 and Exhibit C71, page 3
157
Transcript, page 625
34
accommodation that day. Ms Curtis said that the matter would be followed up via
case management. The outcome of the notification was no abuse confirmed.
4.82. The Court heard from Alan Bruce Johnston who was the manager of the combined
Enfield and Modbury offices during this period. He acknowledged that he authorised
the closing of two of these notifications with no action being taken because there was
no staff to attend to them. He said he would have seen about 20 or 30 such cases each
week158. He said that when they get closed there is no further action taken159. He said
that he and every other manager felt extremely concerned about the risk they were
carrying as a result of these decisions160 and that the issue was raised at regional
manager meetings over many, many years161. Mr Johnstone said at one point the
managers were considering sending all of the closed, no action files through to
executive162. He said that his director, Ms Ellis, was equally concerned but unable to
take any action. He said that he never saw any increased resources as a response to
these concerns163.
4.83. 11 November 2008 to 17 November 2008 – period of chaos for Ashlee and crisis for
Chloe
This period in the chronology comes towards the end of the time of homelessness that
I have just covered and coincides with the commencement of Ashlee’s
accommodation at Taperoo. I will deal with the evidence concerning her period at
Taperoo hereafter. In this section I deal with two notifications in particular in the
period 11 November 2008 to 17 November 2008. It is important also to bear in mind
the context, namely that on 10 November 2008 there had been the notification
referred to above relating to Ashlee being in the park opposite Tea Tree Plaza fighting
with Lagden and Chloe being seen with a can of beer.
4.84. Senior Constable Bentley was a police officer who became involved with Chloe in the
evening of 11 November 2008. On that evening he had a conversation with a person
by the name of Natalie Bretones when he was tasked to an address in relation to the
welfare of Chloe who was in Ms Bretones’ custody. When Senior Constable Bentley
arrived at the premises he saw that Chloe was safe and had been fed. Ms Bretones
158
Transcript, page 644
159
Transcript, page 645
160
Transcript, page 646
161
Transcript, page 646
162
Transcript, page 646
163
Transcript, page 647
35
told him that she had been with Ashlee at Glenelg beach earlier in the day and that
Ashlee was grossly intoxicated by alcohol and at some stage of the day Ashlee had
wandered off and left no contact details and that Ms Bretones had been left with the
custody of Chloe and had no other choice than to return home with her. She could not
contact Ashlee or find any other person suitable to take Chloe into custody. Senior
Constable Bentley did not consider that Chloe was in immediate danger at that point.
Had he done so he would have taken custody of her himself and delivered her to a
Families SA representative. Another police patrol had arrived and so Senior
Constable Bentley was able to go and make further inquiries with Families SA. At
this point it was approximately 9:45pm164. Senior Constable Bentley made a CARL
notification. One of the first lines of inquiry was to try and contact Chloe’s father.
When they spoke with Lagden he refused to take custody of Chloe. He was ‘very anti
police’165. Senior Constable Bentley had returned to the Golden Grove police station
for the purposes of the CARL notification because it is easier to gain access to the
SAPOL mainframe system from a police station. Having contacted Families SA,
Senior Constable Bentley was able to speak to Ms Katrina Heading who was a Crisis
Care response worker and it was to Ms Heading that he made his notification.
Subsequently, Senior Constable Bentley became aware that there had been a number
of further phone calls between Families SA and the police and Ashlee’s mother,
basically trying to find the best place for Chloe to be cared for. He became aware that
in the end a decision was made to place Chloe in a chauffeured car and return her to
her mother’s custody.
4.85. This was Senior Constable Bentley’s last dealing with this matter. The records show
that Chloe was returned by chauffeured vehicle (Brown’s Chauffeured Cars) in the
early hours of the morning of 12 November 2008.
4.86. Further evidence was taken from Ms Heading who raised the intake in the Crisis
Response Unit on 12 November 2008. She said that her assessment was to assign the
matter as a tier 1 case because Chloe was at imminent risk in that the care
arrangement was not sustainable and the police could not find a guardian to care for
Chloe. She said that she spoke to her supervisor, Di Cooper, who agreed with the
tier 1 assessment. Ms Heading spoke to Senior Constable Bentley who was the
notifier. She said that she tried to call Lagden and she tried to call Ashlee and each of
164
Transcript, page 654
165
Transcript, page 657
36
these efforts was unsuccessful. Ms Heading said that she spoke to Ms Valentine to
see if she would take Chloe. Ms Heading noted166 that Ms Valentine would take
Chloe ‘if she must’. At 0021 hours on 12 November 2008 Ashlee had called Police
Communications and was demanding Chloe be returned to her. Ms Heading said that
she rang Brown’s Chauffeured Cars, which is an organisation independent of Families
SA. She was not aware of the identity of all of the drivers employed by that firm at
the time. Ms Heading said that she spoke to Ashlee at 0012 hours and Ashlee was
angry and verbally abusive. Ms Heading said that eventually a decision was made for
Chloe to be returned to Ashlee. She said from her memory she thought that it was
Lou Brown of Brown’s Chauffeured Cars who transported Chloe. She acknowledged
that no member of the staff of Families SA went with Chloe on that occasion. She
said that only two people were available on the nightshift who could have done this.
When asked about the risks involved in sending Chloe with an adult driver in a
chauffeured vehicle, she responded that Families SA used Brown’s Chauffeured Cars
regularly and that they work with children under the Guardianship of the Minister.
She added that there is always some risk. Finally, she said that she has a ‘level of
faith’ in Brown’s Chauffeured Cars. She said that she had used them before and had
never heard of any problems. When asked what was expected to happen at the end of
the journey, Ms Heading said that she expected that Ashlee would be waiting. She
said that she checked in with Brown’s Chauffeured Cars afterwards to see if the
handover was successful and no concerns were noted so she did not make a record of
this. She said that Lou told her that it went fine and that he had given Chloe to her
mother. Ms Heading acknowledged that she did not ask if Ashlee was sober. She
maintained that these actions were all appropriate.
4.87. Ms Heading did admit that it would not have been necessary for the Crisis Response
Unit to have closed down if it had been necessary to attend on Chloe themselves. She
acknowledged that on-call staff were available to fill gaps where needed167. She
maintained that there would have been some period of time when the crisis response
unit was not covered168. Remarkably, Ms Heading said that it would have been
necessary, had a worker from the Crisis Response Unit accompanied Chloe on the trip
back to her mother, for there to be two workers for occupational health and safety
166
Exhibit C91
167
Transcript, page 1096
168
Transcript, page 1096
37
reasons169. By contrast, she was quite prepared for Chloe to travel by herself with a
potentially unknown person. Ms Heading’s evidence was most unsatisfactory. In my
opinion the response on that night was completely unacceptable. Without any doubt it
was entirely inappropriate for a 16 month old child to be allowed to be transported by
a potentially unknown person with a transport firm. Ms Heading maintained that she
believed that it was Lou Brown himself. I have no confidence that she really did
establish that. She made no note of her alleged contact with Brown’s Chauffeured
Cars afterwards to ensure that everything went according to plan170. In short, her
memory was not particularly good and she had no firm basis for her belief that Lou
Brown himself was conducting Chloe’s transport beyond the fact that she had woken
him up when she made the call171. I very much doubt that Ms Heading would have
been prepared to put one of her own relatives in that situation. The fact that it would
have required two workers in order to ensure that their occupational health and safety
concerns were met, but that Ms Heading was prepared to leave Chloe as a hostage to
fate regarding her welfare is preposterous. If it requires two adults to be present in
order for occupational health and safety concerns to be met in the workforce, then it is
preposterous to suggest that it was reasonable for Chloe to be left with an unknown
adult at the age of 16 months. In my opinion Ms Heading completely failed to
discharge her duties to an appropriate standard of care.
4.88. I propose to recommend that Families SA issue a policy prohibiting the transport
alone of a child under the age of 12 years in any circumstances with a chauffeured
delivery service unless in the custody of an employee of Families SA. I also intend to
recommend that the operations of the Crisis Response Unit be reviewed with a view
to determining whether it has sufficient resources and there is sufficient backup for
situations such as that faced by Ms Heading on 12 November 2008. Ms Heading
appeared to have a reluctance to call in a worker who may have been ‘on-call’. There
should be no such reluctance in a situation such as that being faced by Ms Heading.
There should be no hesitation in arranging a call back for an on-call worker in a case
such as that. I am concerned that there may be a reluctance on the part of a person in
Ms Heading’s position to institute a call back because of financial considerations.
Staff should be informed as a matter of policy that the appropriate action is to institute
169
Transcript, page 1081
170
Transcript, page 1078
171
Transcript, page 1077
38
a call back in a situation such as that faced by Ms Heading. There should be no doubt
at all about this and I shall recommend accordingly.
4.89. Before leaving this topic I will deal with the evidence of Belinda Valentine about it.
Ms Valentine said that she received a call in the early hours of the morning from
Crisis Care and was very confused having awoken from sleep. Her husband was
away for work and she had her two sons who were aged 4 and 8 in her care and who
were also asleep. She had only one car seat for her younger child. The Crisis Care
worker told her that she needed to come and get Chloe from the home of a 15 year old
and that Ashlee had been paralytic and had left Chloe in the care of this 15 year old in
the Wynn Vale area. The address was one that Ms Valentine had never heard of and
the suggestion was that she would pick up Chloe and return Chloe to Ashlee the next
day. Ms Valentine said that she had been awakened from sleep and did not fully
understand what was happening. She explained that she would have to take the boys
with her and she only had one car seat. She said it was never suggested to her that an
arrangement could be made for Chloe to be brought to her. She said that was never
offered, but if it had been she would have accepted it. She was asked about the words
that were attributed to her that she would take Chloe ‘if I must’. She said that she did
not say it in that way. Ms Valentine said she said that it would take her an hour and it
would be necessary for her to take the boys and if that was the last option she would
do so. She said she would never have said she would do it ‘if I must’ as bluntly as
that. Ms Valentine said that Ms Heading never came back to her to discuss travel
arrangements. She said that Ms Heading wanted her to speak to Ashlee to see what
state Ashlee was in. Ms Valentine had spoken to Ashlee in the past on the phone
when Ashlee was drunk, slurring her words and so on. Ms Valentine rang Ashlee and
she sounded quite clear, although very angry and was using violent language. She
said she was not drunk and that the girl she had left Chloe with had said she would
take Chloe for the night. Ashlee’s story was completely different from the story that
Ms Valentine had gotten from Ms Heading about what the young girl had said about
being left with Chloe in her care. Ms Valentine said that Ashlee did not sound drunk
to her, but she was threatening her mother that if she took Chloe she would never
allow Ms Valentine to see her again. Ms Valentine said this made her feel very
distressed. She knew Ashlee was a drug user and used methamphetamines. She said
that it was possible that Ashlee’s anger that night was consistent with her having used
methamphetamines, but that she did not know on the night what those effects were.
39
Ms Valentine said that she was upset and then received another call from Crisis Care.
She did not say she could ascertain if Ashlee was drunk or not and she could not
understand why they were asking for her opinion. Ms Valentine said she did not
believe that Ashlee was drunk and that she was concerned about the threat that Ashlee
had made that she would not see Chloe again if she took Chloe. She was very
confused and upset but said that if Families SA had dropped Chloe to her she
certainly would have taken her. She said that she would not have been prepared to
drop Chloe back to Ashlee in the morning because it would not have been safe. Ms
Valentine said she had no recollection of having said to Ms Heading that Ashlee had
been good lately, but acknowledged that she may have done so. She said that her fear
was about returning Chloe to Ashlee the next day.
4.90. I prefer the evidence of Ms Valentine in relation to his event. Ms Valentine’s version
makes sense. Her reaction was that of someone who was called in the middle of the
night, awakened from sleep and having only one child car seat and two small boys in
her care was asked to attend an address she had never attended previously to collect
Chloe. She had only one child car seat for her car and one of her boys needed to use
it. That would leave her with one child who ought to have a child car seat but would
not have one. Furthermore, she would then be faced with dealing with a very angry
Ashlee the following morning, or sometime the following day when she went to
return Chloe to Ashlee’s care. She also was faced with Ashlee’s anger towards her
and Ashlee’s threats that she would not be allowed to see Chloe again if she took
Chloe that night. In my opinion Ms Valentine was placed in an invidious, if not
impossible position. For Ms Valentine’s position to be summed up by the note that
she would take Chloe ‘if she must’ did her a disservice. I have no hesitation in
preferring her evidence to that of Ms Heading.
4.91. Chloe was not in Ashlee’s care for very long following the incident on 12 November
2008 because the records show her being admitted to the Women’s and Children’s
Hospital at approximately 9pm on the following day, 13 November 2008. She was
not in Ashlee’s custody, but rather was with Krystal Benyk who had been driven in by
Nicky Behsmann. This incident was referred to earlier in my finding when I reviewed
the evidence of those two witnesses. The evidence of Ms Claire Haskell, a senior
social worker at the Women’s and Children’s Hospital, was to the effect that Ashlee
did not present with Chloe on the evening of 13 November 2008, but that Ms Benyk
40
stayed with her. The following morning, 14 November 2008, Ashlee was still not
present. The records show that Chloe was discharged to Ashlee’s care sometime in
the middle of the afternoon of 14 November 2008. Ms Haskell gave evidence that
arrangements were made by the Women’s and Children’s Hospital for the Metro
Home Link service to conduct follow-up home visits to Chloe to make sure that she
was well and that her mother was managing with her172.
4.92. Clare McDonald was a registered nurse and a qualified midwife. She was a part of
the Metro Home Link program in 2008 and saw Chloe on 17 November 2008. She
gave evidence that another member of the Metro Home Link team, Nurse Mairi
Martin, had attended Ashlee’s home at Taperoo on 15 November 2008, the day after
Chloe had been discharged the previous afternoon. Nurse Martin saw Chloe sleeping
and Ashlee was obviously making arrangements to move into the house. Nurse
Martin attended Ashlee’s home the following day, 16 November 2008, but was unable
to gain access or to speak to Ashlee. She made a phone call to Ashlee later that day
and arranged for a visit the following day, 17 November 2008.
4.93. It was Ms McDonald who made the home visit on 17 November 2008 at 11am. She
said that Ashlee and her friends were all lazing around watching The Simpsons on
television and showing no interest in Chloe at all, not even Ashlee. Chloe was awake
and looked grubby. She still had her hospital label on and looked uncared for. Ashlee
was not participating in the visit/examination at all. Ms McDonald was left to
examine Chloe while Ashlee watched television. Chloe had not been bathed since she
had left hospital. She was generally grubby with dirty skin. No toys were observed in
the house and as Ms McDonald said, normally a house with a toddler contains many
toys. As a result of the combination of lack of interest by Ashlee, the lack of toys and
Chloe’s condition, Ms McDonald was concerned that Chloe was not being properly
cared for. She notified her concerns to her case coordinator in accordance with their
policy and also advised Ms Haskell who made a notification to Families SA, speaking
to Ms Daniel.
4.94. The Port Youth Accommodation housing at Taperoo
As I have already mentioned, Ashlee commenced a supported accommodation
tenancy at premises in Taperoo under the auspices of Port Youth Accommodation on
or about 11 November 2008. At this point it will be recalled that the Strong Families
172
Transcript, page 681
41
Safe Babies file had been closed, although Ms Daniel, the family support worker, was
tasked to continue working with Ashlee. Shortly after Ashlee entered the Taperoo
accommodation a decision was made for the Strong Families Safe Babies file to be
reopened. There is no record of why that decision was made. It is plain that the
supervisor, Carolyn Curtis, planned to continue with the efforts by Strong Families
Safe Babies to maintain the goal of preserving Chloe and Ashlee as a ‘family’. The
only evidence of the decision to reopen the case is to be found in a case consultation
sheet dated 2 December 2008173. That document states that the case was reopened on
13 November 2008 ‘due to two child abuse notifications being made’. This is clearly
a reference to the notifications discussed above, namely when Chloe was left with the
teenager at Glenelg beach and, secondly, the incident where Chloe was admitted to
the Women’s and Children’s Hospital without Ashlee’s presence. The difficulty with
the date of reopening referred to in this document is that the Women’s and Children’s
Hospital notification did not come to the attention of Families SA until 14 November
2008. It also makes reference to two intakes but in fact by 14 November 2008 there
were three, including the episode where Chloe was seen with the can of beer at the
park opposite Tea Tree Plaza. It remains a mystery when the decision to reopen the
case was actually made, but it was clearly sometime between 14 November 2008 and
2 December 2008. This is a further example of the appalling state of the records and
the poor note keeping that manifests itself throughout this case. Concerningly, the
case consultation sheet says:
‘Strong Families Safe Babies do feel that the mother has insight in relation to Chloe’s
physical and emotional needs, however is often tempted to take the easy option.’ 174
In the light of the events giving rise to the incident at Tea Tree Plaza, the incident at
Glenelg and the incident at the Women’s and Children’s Hospital, all of which
occurred only a couple of weeks before this document was written, it is difficult to see
how Strong Families Safe Babies could have reached that conclusion. This is an
example of what counsel assisting referred to as the Strong Families Safe Babies team
‘blindly searching for something optimistic in this family picture, as if to reinforce
their perceived success at intervention’175. It was Ms Curtis’ evidence that at this
point her priority was to ‘get a social worker in there and allocate it as quickly as
173
Exhibit C68, page 236
174
Exhibit C68, page 236
175
See submissions of counsel assisting
42
possible to gain a much clearer picture of what was happening for Chloe’176. The
social worker allocated for that purpose was Leanne Stewart. Ms Stewart joined the
Strong Families Safe Babies team in January 2009 and worked on Chloe’s case with
Ms Daniel who continued as the family support worker.
4.95. The Port Youth supported accommodation in Taperoo continued until around July
2009. This was another supported accommodation arrangement with the requirement
of the tenancy once again being that a support worker would work closely with
Ashlee to help her attain parenting goals and independent living skills. Again this
arrangement failed as will be seen through the evidence of Ms Stewart. It is not
surprising that it failed. Nothing had changed in Ashlee or her willingness to give
Chloe’s needs precedence to her own desires. In the result Chloe was subjected to
another unhygienic living environment with parties being held at the property and
very likely Chloe being exposed to drug taking. Over this period three intakes were
raised. One concerned a number of things including the disrepair of the house, broken
bottles in the front yard and Ashlee’s non-compliance with the support provided by
Port Youth Accommodation. Another related to Ashlee being punched twice in the
face and being threatened with a knife while she was holding Chloe. On this occasion
the assault was allegedly carried out by Lagden. Ashlee conceded to the worker that:
‘Chloe had clung to her really hard and that Chloe had not cried as she has got used to
violent incidents as she had experienced them in the past.’ 177
Child abuse was confirmed on that occasion but nothing substantially changed other
than Ashlee and Chloe finally being given notice of eviction from Port Youth
housing. During this period the addition of the senior social worker in Ms Stewart did
not seem to make any real difference to Ashlee’s attitude to her obligations towards
Chloe. This is clear from the lack of respect she displayed towards Ms Stewart and
Ms Daniel. Ashlee eventually ended up abandoning the house at Taperoo before
being evicted, once again leaving chaos in her wake.
4.96. Ms Stewart gave evidence of her various efforts which she described by what was
apparently a term of art within Families SA, or within Strong Families Safe Babies,
namely ‘scaffolding’178. Ms Stewart’s first home visit took place on 5 January 2009.
On that occasion Chloe appeared dirty and unkempt and was only wearing a nappy.
176
Transcript, page 1484
177
Exhibit C68, page 256 and Transcript, page 776
178
Transcript, pages 947-948
43
She was in her bouncer which was not suitable for a child of her size. Alice Arsenias
from Port Youth Accommodation had contacted Ashlee in relation to damage to her
property. On 9 January 2009 Ms Stewart told Ashlee to report a broken window at
the house. On 13 January 2009 Ashlee still had not made that report and on
16 January 2009 Ms Stewart arranged to take Ashlee to the Port Adelaide police
station to report the damage. However by then the police had already made their own
investigations, presumably at the instigation of Port Youth Accommodation. 20
January 2009 brought another home visit. On this occasion179 Ashlee told Ms Stewart
that her reason for leaving Chloe with inappropriate people was that she felt that she
needed ‘respite’. As a result of this Ms Stewart said that Strong Families Safe Babies
decided to organise weekend respite for Chloe with the organisation ‘Time for Kids’
which is a non-government organisation staffed by volunteers to take children for
respite for periods over weekends. Ms Stewart completed a Time for Kids referral
form with Ashlee. During this process she described Ashlee as rolling her eyes. Ms
Stewart said that Ashlee maintained the position that things she had done in the past
were over and became frustrated when, in documents such as the referral form, past
issues were referred to.
4.97. On 2 February 2009 Ms Stewart obtained information from Ms Kate Wallis that she
had looked after Chloe for five days. She said that she was happy to do so but was
concerned that Chloe was underweight and her ears were badly blocked with wax.
Ms Wallis was also concerned about Chloe’s development generally. Ms Wallis had
been told by Ashlee that Ashlee had been involved in a domestic violence incident
with her then partner, Michael, with whom she had just broken up. Interestingly, on
that same day Mr Polkinghorne (Ashlee’s father) had contacted Ms Stewart to advise
that he was concerned about Chloe’s development. He also wished it to be noted on
the file that if Chloe was unable to remain in Ashlee’s care, he would like to be
considered as a carer for her180. Mr Polkinghorne was another member of Chloe’s
extended family within the meaning of that definition in the Children’s Protection Act
1993, as was Ms Valentine. Each of them expressed a desire at various times to take
Chloe into their care. Placement of Chloe with either of those two people would have
been consistent with the objective in the Children’s Protection Act 1993 of
maintaining Chloe in a stable family environment. However, it appears that no
179
Exhibit C68, page 200
180
Exhibit C68, page 192
44
consideration was ever given to that and Ms Stewart’s evidence was that she did not
believe at the time that Strong Families Safe Babies would have met the threshold
criteria to succeed in an application to the Youth Court for custody orders for
Chloe181. Of course, there are many other options that the Youth Court might have
been prepared to consider. The only option that any of the witnesses referred to in
this context was the option of permanent removal of Chloe from Ashlee’s custody182.
4.98. As a result of the concerns expressed by Ms Wallis and Mr Polkinghorne, Ms Stewart
made attempts to contact Ashlee on 5 October 2009. In fact she rang on no less than
four occasions183. Finally, when she got through Ashlee told her that she would not be
home and that Ms Stewart could visit the following day. Ms Stewart informed her
that it was urgent because Strong Families Safe Babies had received another
notification. Ashlee replied ‘are you fuckin‘ serious? It was my dad wasn’t it?’
Ashlee then asked Ms Stewart to call her in an hour’s time. Remarkably, Ms Stewart
complied with this request. No consideration was given by her to the option of, for
example, arranging for a family care meeting to be convened under section 27 of the
Children’s Protection Act 1993. However, as the evidence showed, Families SA
rarely made applications under that provision except as a precursor to an application
for permanent custody of a child. Ashlee was showing by her attitude to Ms Stewart
as early as this that she was not according Ms Stewart very much respect. By the
strategic application of the tools available to Families SA under the Children’s
Protection Act 1993 Ms Stewart could have caused Ashlee to change her focus and
become compliant with Families SA’s goal of improving her parenting. I do not
suggest that this should be done for the purpose of winning a victory over Ashlee, or
scoring some points in some ghastly game between Families SA and this recalcitrant
young woman. I suggest that intelligent application of the legislative tools available
to secure compliance with Families SA’s goal of forcing Ashlee to be a reasonable
parent should have been the true objective. After all, that was the only option
available to Families SA if it did not move to remove Chloe. It could either allow the
matter to drift aimlessly, or it could use whatever tools it had available to it to force
Ashlee to do what was necessary. Unfortunately, Families SA took the path of least
resistance and the whole history of its dealing with Ashlee is a history of drift,
181
Transcript, page 747
182
In Exhibit C120 the Senior Judge of the Youth Court has said that Families SA has a rigid approach to care and protection,
seeking long term custody orders rather than alternatives that may be better tailored to the particular case
183
Exhibit C68, page 187
45
irresolution and aimlessness. Had Families SA intelligently and strategically applied
the legislative tools available to it much more readily, and much earlier, there is every
chance that one of two things would have happened. The first possibility is that
Ashlee might have changed her ways and become a more responsible parent. As
unlikely as that now seems, it must have been a possibility given her very young age
and the extended family assistance that would have been available to her if she
modified her behaviour. The other possibility is that by increasing the pressure on
Ashlee through the strategic and intelligent application of the legislative options, the
agency would have brought the matter to a head in the short to medium term. By this
I mean that if a family care meeting had been convened and its stipulations and goals
had not been met by Ashlee, the next stage would have been to elevate the matter for
strategic orders from the Youth Court, for example drug assessments, vocational
training and so on. If those goals had not been met by Ashlee, then the Youth Court
could have been persuaded without much difficulty to have removed Chloe from
Ashlee’s care for a short or longer term period.
4.99. Had these courses been adopted, it is easy to see that the tragic outcome, namely
Chloe’s death, might have been avoided.
4.100. Instead, the matter was left to drift along with Families SA busily ‘scaffolding’
around Ashlee and acceding to Ashlee’s demands and excusing her failings.
4.101. In any event Ms Stewart discussed the notification with Ashlee and she agreed that a
meeting could be arranged with her mother being present. A meeting was arranged
on 9 February 2009 but Ms Valentine was not present and it turned out that she and
Ashlee had had an argument. The various allegations were put to Ashlee but the
house was tidy and clean as Ashlee knew that Ms Stewart was coming. The result of
the notifications was that abuse was not confirmed. Ms Stewart’s note of 9 February
2009 records the following:
‘It is SSW184 assessment (sic) that at times Chloe is exposed to less than perfect parenting
by Ashlee, however it is SFSB ongoing assessment that Ashlee’s level of parenting is
considered above the threshold of ‘adequate’ and ‘good enough’.’ 185
This is a particularly concerning note. The reference to a threshold of adequate and
good enough in this context is highly subjective. It seems to me that Ms Stewart and
184
SSW means senior social worker and is a reference to Ms Stewart
185
Exhibit C68, page 177
46
others in Families SA have adjusted their opinions of adequate and good enough
markedly below what would be considered adequate and good enough in the general
community. No doubt in the subset of families and persons who come to Families
SA’s attention in a child protection context, the standards are much less than those of
the general community. There is a danger that the perspective of what is adequate and
good enough is distorted in this situation.
4.102. On 3 March 2009 Ms Stewart wrote on behalf of Ashlee to Housing SA seeking
public housing for her. The letter was written in the knowledge that the Port Youth
Accommodation option was only for twelve months at a maximum and that Ashlee
would need to find alternative accommodation by November 2009. However nothing
came of this application. On 7 March 2009 there was a notification from the Crisis
Response Unit who had received a call from Ashlee stating that Lagden had punched
her twice and pulled a knife on her. Lagden was ‘off his head’ on drugs at the time.
While the assault was occurring Ashlee was holding Chloe. Ashlee had a bloody lip,
but Chloe was not hurt. However, during the incident Chloe had ‘clung to her really
hard’ and Ashlee went on to say that Chloe had not cried and that she had got used to
violent incidents as she had experienced them in the past186. A second notification
about the same incident came in from Alan Polkinghorne.
4.103. Following this report a meeting was arranged between Ms Stewart, Ms Curtis the
supervisor and Ashlee to discuss the domestic violence by Lagden and another recent
incident involving Michael. It was suggested by Ms Curtis that Ashlee report the
matter to the police and get a restraining order. Ashlee became upset about this
suggestion and said that she would be put at huge risk of harm if that happened. She
feared repercussions or payback from friends of Lagden. No significant steps were
taken following this meeting other than continuing with the status quo. Then, on
30 March 2009 Ashlee reported that her unit had been ‘crashed’ by eight males and
that damage had been sustained to the walls of the house. A home visit on 2 April
2009 showed Chloe to be crying and dressed in a nappy with Ashlee and a male
outside smoking. On 6 April 2009 Ms Arsenias from Port Youth Accommodation
contacted Ms Stewart to advise that she and Ashlee were not getting on well. The file
records that the damage that resulted from the males ‘crashing’ the unit was reported
to the police, however Ashlee lied to the police and stated she did not know who was
186
Exhibit C68, page 256
47
responsible. Ashlee was also noted to have two black eyes as a result of an assault
she sustained in that incident. On 15 April 2009 Ms Daniel attended at the Taperoo
property having carried out some errands for Ashlee. On returning to the unit Ms
Daniel overheard a male voice saying ‘I’m going to have another bong, do you want
one?’. Chloe was in the vicinity at the time187. On 20 April 2009 there was a further
notification which referred to parties at the home and people coming in from off the
street and the associated risks to Chloe. The following day there was a meeting with
Ms Stewart, Ms Daniel, Ashlee and the manager and housing worker at Port Youth
Accommodation. The Port Youth Accommodation staff said they did not believe that
Ashlee was engaging with the support worker they were providing.
4.104. Concerningly, on 20 May 2009 Ms Stewart was driving Ashlee to West Lakes
shopping centre when Ashlee received a phone call. The note that was made by Ms
Stewart suggested that Ms Stewart thought that the phone call was to arrange the
purchase of drugs. Ms Stewart put this to Ashlee who denied it, but her response was
not convincing to Ms Stewart188. The same day a phone call was received from Port
Youth Accommodation advising that Ashlee’s tenancy was not sustainable and that
Ashlee was to be evicted.
4.105. By 24 July 2009 it was clear that Ashlee had herself left Port Youth Accommodation
and was living elsewhere, but was not prepared to provide an address to Families
SA189. In late July 2009 Ms Stewart spoke with Ashlee who claimed that she did not
know what her new address was. By 3 August 2009 Ms Stewart had ascertained that
Ashlee’s new address was in Rostrevor. A letter was received from Port Youth
Accommodation the following day to the effect that Ashlee’s abandoned house had
been left in a filthy condition. This came as a surprise to Ms Stewart. However, it
seems to me to be entirely consistent with Ashlee’s history in relation to her housing.
4.106. Ms Stewart said that the next significant event occurred on 10 August 2009 when she
spoke to Ashlee following contact that she had received from the Time for Kids
volunteer to the effect that Ashlee had been involved in some kind of incident on
7 August 2009. Ms Stewart spoke to Ashlee about this report and Ashlee advised that
she had been assaulted on 7 August 2009, but she refused to disclose who the
perpetrator was. She refused to give any further details to Ms Stewart and said she
187
Exhibit C68, page 88
188
Exhibit C68, page 120
189
Exhibit C69, page 73
48
would speak to Ms Stewart on Thursday. 10 August 2009 was a Monday and the
Thursday was 13 August 2009. Ms Stewart met Ashlee on 13 August 2009 at Tea
Tree Plaza. Ashlee told her that she had left the Rostrevor house and told her that she
had been assaulted by a person call Dylan but that she had broken up with him.
Ashlee refused to give Ms Stewart Dylan’s surname. Ashlee also disclosed that the
assault upon her by Dylan had resulted in bruising and possible fractured ribs and a
possible fractured wrist and that Chloe may have witnessed the incident. Ms Stewart
said that she did not report this to the police and furthermore she did not make any
notification to CARL because Ms Curtis had told her not to do so. Six days later on
19 August 2009 Alan Polkinghorne informed Ms Stewart that Dylan’s surname was
Hindle. Mr Polkinghorne suggested that Ms Stewart conduct a Google search on that
name. To sum up, the information obtained by Ms Stewart on 13 August 2009 was
that Ashlee did not intend to report the matter to police and that Ashlee did not intend
to seek medical assistance. Clearly this was a time at which the matter should have
been escalated to the Youth Court, however that did not happen. Ms Stewart could
not remember why she did not ring the police to report the matter herself. She
suggested that it may have been because Families SA only knew Dylan’s first name
prior to the information from Mr Polkinghorne. This is, with respect, ridiculous
because the police would have been able to investigate simply on the basis of the first
name and the address which Dylan was known to be living at. As a public officer,
Ms Stewart had been informed of a crime. In my opinion it was her duty to report this
matter to the police regardless of Ashlee’s attitude to the matter. That was Ms
Stewart’s duty as a public officer and the duty of any other Families SA worker who
became involved in the situation. In my opinion that should have occurred at the very
least.
4.107. As a result of speaking with Mr Polkinghorne, Ms Stewart did indeed conduct an
internet search under the name Dylan Hindle. She found a newspaper article online
about Hindle having a sexual relationship with a girl under the age of consent. Hindle
had taken photographs and video of this activity without the girl’s permission. He
was placed on the National Sex Offenders Register as a result of this conviction.
Unbelievably, Ms Stewart said that although she thought that Ashlee needed to know
about Hindle’s history so that she could make appropriate decisions about having
contact with him, Ms Stewart was ‘not sure whether I was able to disclose that to her
49
from a confidentiality perspective’190. She said that she had also become aware of
some further information about Hindle from Families SA’s client information system
and it was this that caused her to be concerned about confidentiality. She sought
advice from a supervisor called Brenton Carr and the result was that she was not
allowed to provide the information about Hindle to Ashlee. Bizarrely, Ms Stewart
understood from Mr Carr that she was not even entitled to tell Ashlee that which she
had found on the publicly available internet191. Ms Stewart was questioned at some
length about this issue192. Her position in relation to this matter was simply
preposterous. On no view could any sensible person arrive at the conclusion that
information they had obtained in the public domain could not be conveyed in these
circumstances, particularly where Ashlee needed to know about the history of the man
she was involved with. It is frightening and concerning to think that Ms Stewart
could reach such a bizarre conclusion, particularly after conferring with a colleague
who apparently agreed with her. It is difficult to comprehend how an organisation
could produce two employees who would reach a conclusion such as this. It is only
possible to conclude that there are serious deficiencies in the training of Ms Stewart,
Mr Carr and any other person who would operate in this way.
4.108. It was pointed out to Ms Stewart that she was then in possession of information from
a newspaper about the terms of Hindle’s sentence which was a suspended sentence of
imprisonment. She was also aware that Hindle had been involved in an alleged
assault of Ashlee. Putting those two pieces of information together would almost
certainly establish a breach of the condition of the suspended sentence. This was
another event that urgently needed to be reported to the police, but Ms Stewart failed
to do that, as did other employees of Families SA. This is a matter that deserves the
most condign criticism.
4.109. On 19 August 2009 Ms Stewart made a notification about these events and assessed it
as ‘no grounds for intervention’. She said the people from Crisis Care agreed with
this assessment. She said she would have consulted someone senior about the
removal of Chloe, but there is no note to that effect. She maintained that at that point,
it being some twelve days since the assault, grounds could not be made out for
removal of Chloe from Ashlee’s care pursuant to section 16 of the Children’s
190
Transcript, page 868
191
Transcript, page 869
192
Transcript, pages 870-871
50
Protection Act 1993 which is the power of an officer of Families SA to remove a child
who is in a situation of serious danger. She went on to add that:
‘So we would have been looking at a planned application which can take several weeks,
sometimes months to go through the process.’ 193
In this respect I take her to be referring to an application to the Youth Court under
part 5 of the Act. Ms Stewart acknowledged that she believed that Families SA would
have been granted an investigation and assessment order, but was not confident that
they would have been given custody of Chloe194. However, as a matter of fact, no
such application was made. In my opinion there is no doubt that this was another
time when Families SA could have applied the various legislative tools that were at its
disposal under the Children’s Protection Act 1993. I have rehearsed them elsewhere
in this finding. No action to that effect was taken. This represents another lost
opportunity. This notification was opened and closed on the same day, namely
19 August 2009. Another day, another lost opportunity to procure a brighter future
for Chloe.
4.110. On 9 September 2009 the Strong Families Safe Babies team wrote a letter to the
organisation known as Louise Place which is yet another form of supported
accommodation. It was their hope that Louise Place would provide Ashlee with
accommodation. Ms Stewart agreed that she would have looked at this letter before it
was sent. She acknowledged that the letter, which states that Ashlee was ‘observed to
maintain the home environment to an appropriate standard’ and that for some time
Ashlee has not been engaging in substance misuse, was plainly false195. Ms Stewart
said that the letter was written because there were no other, or few other, options for
Ashlee at that point. Ms Stewart said that perhaps her threshold for what was okay
and what was not okay had shifted196.
4.111. In any event Ashlee and Chloe moved into Louise Place and Strong Families Safe
Babies made arrangements for Chloe to go into the Unley Child Care Centre five days
per week under a special child care benefit197. On 10 December 2009 the director of
the Unley Child Care Centre reported that when Ashlee dropped Chloe off, Ashlee
smelt of alcohol.
193
Transcript, page 879
194
Transcript, page 880
195
Transcript, pages 899-900
196
Transcript, page 902
197
Transcript, page 903
51
4.112. From the time that Ashlee entered Louise Place, Ms Stewart was having less to do
with the case. The bulk of the work from that point was being undertaken by Janelle
Morris who was at that time a social work student who was undertaking a placement
at Families SA. Ms Stewart said she thought that Ms Morris had the skills to manage
Ashlee in this situation, despite the fact that she was merely a social work student,
albeit in her final year, completing a placement at which she was supposed to be
obtaining training, supervision and experience198. Clearly it was inappropriate that Ms
Morris became the lead worker during this period.
4.113. Ms Stewart’s final involvement with Ashlee occurred on 7 January 2010. Ms Stewart
said that at that point Ashlee had been evicted from Louise Place. Ms Stewart
collected Ashlee from her new address in Flinders Park and she had what she
described as a very serious conversation with Ashlee about her behaviour, her
lifestyle and her choices and the impact that was having on Chloe. She said:
‘I can recall talking to her about it getting to a point where we were not seeing enough
shift from her, she hadn’t been able to maintain … the case had been open for … two and
a half years, that a decision needed to be made as to what happened from here. My
recollection of the meeting was that we had gotten to the point that we were saying to
Ashlee that we were escalating the matter. We were considering first of all going to a
family care meeting which is more formal, that is held at the care and protection units,
that is more formal than the family meeting.’ 199
4.114. Ms Stewart was very vague about why this information was conveyed to Ashlee on
that occasion. She acknowledged that there were gaps in the notes. She said she
assumed it was part of a broader case direction that was given to her by her
supervisor, Ms Curtis, but that it was not recorded. She said that something must
have happened prior to her conversation, but it was not recorded on the file and she
was not clear why200. She said it may have been that a review was conducted, but she
acknowledged that there was no documentation of it and nothing to indicate what was
the catalyst for this discussion that she had with Ashlee201. Ms Stewart said that she
believed that she would have given Ashlee a timeframe to demonstrate sustained
change, saying ‘it probably would have been between three and six months from
memory’202 and then noting that it was probably six months203. This was Ms Stewart’s
last substantive involvement in the case.
198
Transcript, page 922
199
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200
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201
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202
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4.115. Elizabeth Daniel
I heard evidence from Ms Daniel who confirmed that she was the family support
worker involved with Ashlee and Chloe over the two year period in question.
Ms Daniel said that when Mr Ratsch left Strong Families Safe Babies on 12 April
2008 because he had a new job, it was at the time Ms Daniel’s understanding that the
supervisor, Ms Curtis, would assume the case management responsibility for Ashlee
and Chloe204. However, she agreed that that did not happen and that the case
management was essentially left to her, although she was able to get directions from
Ms Curtis and a social work student was allocated to the case also. That student was
Amy Kidner205.
4.116. When Ms Kidner expressed concern in late May 2008 that Chloe had not been seen
by a qualified social worker for a month Ms Daniel shared her concern. Ms Daniel
said that this was the outcome of there being no senior social worker case managing
the file, but noted that it was really Ms Curtis’ responsibility given that she had taken
the case management to see Chloe more regularly206.
4.117. Then, on 6 June 2008, Ms Kidner was attempting to see Chloe but was not able to and
spoke instead to Ashlee and she requested Ms Daniel’s assistance to ensure that Chloe
was seen207. Ms Daniel acknowledged that it was possible that Ms Kidner was not at
the time getting the role modelling from a person in a senior position that she should
have been208. In any event, Ms Daniel approached another senior social worker,
Daniel Frick, who was not assigned to Chloe’s case, but was willing to assist. She
approached him to ask him to step in because she needed someone senior in a social
work role to be assertive with Ashlee about producing Chloe to Strong Families Safe
Babies209. Ms Daniel said that Ashlee was at first resistant to Mr Frick’s attempts to
see Chloe210, but that Mr Frick was effective in that he firmly persisted and then was
able to see that Chloe was safe. Ms Daniel said that Mr Frick was definitely ‘more
assertive than what I had seen’211.
203
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205
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206
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207
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208
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4.118. Ms Daniel confirmed that on 21 July 2008 Ms Curtis closed the file ‘on the system’212.
Ms Daniel said that she was directed to continue working with Ashlee even though
the case was closed on the system213. Ms Daniel said that over the next few months
she did not see Chloe and did not know how things were going with her214. Up until
20 October 2008 Ms Daniel said it was only she working on the case but with
guidance from Ms Curtis. She said that she did have trouble engaging with Ashlee
over that period215. Ms Daniel said that by the time of the three intakes which
occurred around 12 November 2008, which I have referred to above216, she was
concerned that possibly not enough was being done to keep Chloe safe, but she added
‘I don’t know what else you would do because you’re not with them 24/7’217. That is
a revealing remark because it suggests that the only way to keep Chloe safe was to be
present 24 hours per day. Effectively this is a concession that Chloe should not have
remained with Ashlee but that some other solution should be found to keep Chloe
safe. Following the admission of Chloe to the Women’s and Children’s Hospital
Ms Daniel spoke to Ashlee who actually suggested that she believed that Ms Benyk
and Ms Behsmann had given Chloe something to make her vomit and that Ashlee was
‘being set up’218. Of course those suggestions are fanciful, but there is no sign of
Ms Daniel being firm with Ashlee to that effect. Ms Daniel said that at this time it
definitely seemed to her that Strong Families Safe Babies could have been doing more
to preserve Chloe’s safety. She said that they needed to ‘make Ashlee accountable for
her actions’ by being stricter with her219. Ms Daniel said that she left Families SA in
2010 following the birth of her own child. She said that she could not cope with
working in the child protection area after that ‘seeing and knowing what was
happening to children, young children and probably not being able to do as much as
you want to change that for them’220.
4.119. Janelle Morris
It will be recalled that Janelle Morris was the student social worker who was involved
with Ashlee between August and December 2009 during the period that Ashlee was at
Louise Place. Ms Morris completed her social work degree in 2009 and was, in that
212
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213
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214
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215
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216
Chloe with beer can, Chloe left with teenager at Glenelg, Chloe admitted to Women’s & Children’s Hospital without Ashlee
217
Transcript, page 1020
218
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219
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220
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54
year, a student. She was doing her final placement for the purposes of her course with
the Strong Families Safe Babies team in the last few months of 2009. She confirmed
that although she was a student social worker, she was the primary worker dealing
with Ashlee and Chloe for much of that period221. She said that her supervisor during
that period was Ms Stewart. At the time of giving evidence Ms Morris was a stay at
home mother. She commenced work as a qualified social worker with Families SA in
February 2010 and worked in that capacity for just over a year until, in March 2011,
she took leave to have her first child. She has not been in the workforce since that
time. Thus, her total experience, apart from her placements as a student, amounts to
just over one year as a qualified social worker. Despite this she presented as being
very confident in her opinions about child protection. She made a stark contrast with
Ms Kidner who was a much more measured witnesses, who was far more prepared to
make appropriate concessions.
4.120. Ms Morris said she was aware that Ashlee’s previous supported accommodation had
been unsuccessful but options were limited and it was necessary to get Ashlee a place,
hence Louise Place was an attractive option. She did think that Ashlee should have
been told before going to Louise Place that she was at risk of losing Chloe if she did
not make it successful. On 25 September 2009 there was a case conference. At that
time Ms Stewart was to become the acting supervisor of the office for six weeks and
so Ms Morris was to take the lead role with Ashlee and Chloe. On 1 October 2009
Ms Morris made a home visit to Ashlee at Louise Place and found it to be messy but
not unhygienic. She said that already Ashlee was expressing frustration with Louise
Place’s restrictions and rules. Ashlee acknowledged that she had anger management
problems. On 7 October 2009 Ms Morris visited again and found Chloe in a singlet
and nappy with a runny nose and dirty face. The house was messy and strewn with
rubbish, but not large amounts. On 8 October 2009 Sherilee Kartinyeri from Louise
Place was expressing concerns that it may not be the right placement for Ashlee. The
following day Ms Kartinyeri expressed further concerns and remarked that Ashlee
was outspoken and would not follow rules, and that Louise Place had arranged for her
to come to a meeting. If she failed to attend the meeting she would be given seven
days notice of eviction. Ms Kartinyeri did not think that Louise Place was appropriate
for Ashlee and said that the option of outreach housing following her placement at
Louise Place would not be made available. Ms Morris maintained that she felt that
221
Transcript, page 1168
55
she was capable of handling the situation. She said she had a lot of conversations
with Ms Stewart and these were informal and not noted. Ms Morris said that she was
unable to attend the Louise Place meeting because she only worked three days per
week.
4.121. The next report from Louise Place noted that Ashlee had been extremely rude and
returned to the complex intoxicated by alcohol. She was placed on probation for one
week. Ms Morris said it was concerning because very soon Ashlee would not have
accommodation at Louise Place if this continued. She said that Ashlee ‘struggled’
with the restrictions. In early October 2009 as a result of the fears about Ashlee
losing her accommodation at Louise Place, Ms Morris had a conversation with Ashlee
in which she said that there were decision makers outside the Strong Families Safe
Babies team who were watching the case with a view to making decisions about what
was best for Chloe’s care because of Ashlee’s transience having been a pattern and
Ashlee not prioritising Chloe’s needs222. This reference to people watching was
designed to imply to Ashlee that she might be at some risk of losing Chloe if she did
not improve her behaviour. The decision to have this conversation with Ashlee
followed a discussion with Ms Stewart that was an ‘informal chat’ and ‘it wasn’t
practice to actually record those informal chats, or perhaps I intended to and I
forgot’223. In any event there is no note of any decision being made by Ms Stewart or
anyone else to authorise the conversation implying that other people were watching
with a view to making decisions about Chloe’s care.
4.122. Ms Morris said that she was on leave in October 2009 and could not say who was
attending to Chloe and Ashlee’s case in her absence. She said that it was possible that
no-one did, although suggested that Ms Daniel may have. On 16 October 2009 Ms
Stewart received a call from the director of the Unley Child Care Centre to say that
she had observed Chloe in an extremely full nappy and had never seen a nappy as full
in her 9 years of experience. Shortly after this Ms Kartinyeri from Louise Place told
Ms Morris that Ashlee was going to be asked to leave. She met with Ms Kartinyeri
on 27 October 2009. Ashlee was present also. The Louise Place staff said to Ashlee
that they questioned her understanding of her responsibility to Chloe and safely
parenting her. They said that Ashlee refused to see Chloe’s needs as a priority and
focussed only on her own. They said Ashlee became even more defensive when they
222
Transcript, pages 1214-1215
223
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56
try to address child protection issues. The staff from Louise Place asked Ashlee what
her plan now was with respect to Louise Place, in other words whether she would
abide by their rules. She replied that she had nowhere else to live and would try her
best to stick by the rules. The staff from Louise Place reminded her that it was not
just a matter of sticking to the rules but her willingness to participate224. Ms Morris
acknowledged that it was not ‘ideal’ for her to attend this meeting without the support
of a senior social worker, or indeed any qualified social worker at all, but explained
that it was because of staff shortages225.
4.123. On 29 October 2009 Ms Morris conducted a home visit with Ashlee. After some
difficulty she gained access to the unit. Ms Morris drove Ashlee and Chloe to the
Unley Child Care Centre and then returned with Ashlee to the unit. Once they
returned Ms Morris told Ashlee that she would have to think very seriously about how
she was going to ensure her continued accommodation at Louise Place. Ms Morris
told Ashlee that ‘there are other people within Families SA above Leanne and
Carolyn who are making decisions around what is considered to be in Chloe’s best
interests’226. Ashlee responded by becoming extremely angry saying that she would
run away and that Families SA could not take Chloe. She used expletives. She also
stated that she hated Families SA. Ms Morris then explained to Ashlee that she did
not say that Chloe was going to be removed, just that other people within Families SA
were discussing Chloe’s wellbeing and had the authority to make decisions about her
care. They discussed Ashlee’s anger management problem and Ashlee said ‘I
wouldn’t be angry all the time if you c**** weren’t always interfering’227. Finally,
Ashlee said that although she hated Louise Place she was willing to stay there until
she got a job and her own house. Ms Morris told Ashlee that she and Ms Stewart
wished to organise a family meeting to determine ‘what support family members can
provide to Ashlee and Chloe’. Ms Morris explained that the intention of the family
meeting was that she and Ms Stewart were wanting to get all of the family members
together to see if they could arrange further support for Ashlee and Chloe of any form
at all. Once again the casenotes contain no indication of who it was that suggested the
notion of a family care meeting or the suggestion that there were people higher up
giving consideration to Chloe’s welfare228.
224
Transcript, pages 1224-1225
225
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226
Exhibit C72, page 148
227
Exhibit C72, page 148
228
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57
4.124. At first in her evidence Ms Morris suggested that the proposed meeting with the
family would be a family care meeting under the Children’s Protection Act 1993.
However she changed her mind and acknowledged that it was probably an informal
family care meeting229. In my view that is clearly the case because there is no
suggestion whatsoever that at any point consideration was given to invoking section
27 of the Act for a properly constituted family care meeting. That ought to have
happened but it never did.
4.125. In any event, there was a degree of to-ing and fro-ing about the family care meeting.
Ms Morris wanted Ms Valentine to take part in the family care meeting but Ms
Valentine told her that she and Ashlee had been together the previous week and it
ended badly with Ashlee blaming her mother for everything and using foul language
around her mother’s young children. Ashlee told Ms Valentine that she blamed her
for Dylan’s assault. Ms Valentine also pointed out to Ms Morris that Chloe was in
child care four days per week and staying with Joy from Time for Kids every
fortnight. She questioned what Ashlee was doing with the rest of her time. Ms
Valentine said that she did not understand why Ashlee was not coping if she was not
having Chloe in her care for much of the time230. Ms Morris told Ms Valentine that
Ashlee and Chloe had a ‘decent attachment’. She explained this statement as follows:
‘Because despite people’s concerns, we believed at the time, or I believed at the time that
they still had – it was not a perfect attachment by any means but in a kind of child
protection scenario, we would sometimes refer to it as good enough. I know that doesn’t
sound ideal by any stretch of the imagination, but that is the reality of this work and you
learn that very quickly.’ 231
4.126. This world weary description of the reality of child protection work does not sit well
coming from the lips of a person who has had barely more than one year of
experience in the field. It seems to me that Ms Morris was over confident and had too
high an assessment of her own capabilities. She was certainly not in a position to
make that assessment.
229
Transcript, page 1242
230
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231
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58
4.127. Ms Morris informed Ms Valentine:
‘That recently Ashlee had become very close to having Chloe removed from her care and
that this meeting was about showing a united front and ensuring that each person
involved with Ashlee were saying the same things.’ 232
4.128. Ms Morris was questioned about that statement and why she said it. She said she did
not know why she wrote that she had said that to Ms Valentine. She simply could not
explain it and said that she should not have said it to Ms Valentine233. She said that
the comment may have been as a result of conversations she had had ‘with
supervisors’ and that there were conversations taking place between her and the
supervisors about ‘possibilities’234. When she was asked where the conversations with
the supervisors were noted in the file, she said ‘it was informal chats mostly and they
are not noted’235. She said she did not know why they were not noted and said they
should have been. When she was asked why she was giving incorrect information out
to family members she responded:
‘On this one occasion it appears that that happened. It was – I’m – as I’m aware a one-off
and we all make mistakes, especially when we’re learning.’ 236
With considerable reluctance Ms Morris finally conceded that the support she
received from Families SA as a social work student was not sufficient237. In any
event, the proposed family care meeting did not proceed because Ms Valentine
received a telephone call in the meantime from Ashlee who was being abusive and Ms
Valentine said that as a result of that she would not be attending the meeting238. It
appears that Ashlee informed Ms Morris that Ms Valentine had asked Ashlee what the
purpose of the meeting was and Ashlee said that it was about how she, Ms Valentine,
could support Ashlee and Chloe. Ms Valentine remarked that she did not need to
learn how to support them as she already did this and this resulted in a fight. Ashlee
said that if her mother would not come to the meeting then there would be no point in
having it239, a position that Ms Morris accepted. This is a further example of Ashlee
controlling the situation and Families SA complying with Ashlee’s wishes. The
decision as to whether there should be a meeting or not should have been a matter for
232
Exhibit C72, page 110
233
Transcript, page 1298
234
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235
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236
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237
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238
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239
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59
Families SA to determine and not Ashlee. Yet Families SA allowed Ashlee to take
charge. Ms Morris conceded that should not have happened240. She conceded that
this was an example of her being out of her depth241.
4.129. On 26 November 2009 Ms Morris conducted a further home visit to the Louise Place
unit. Before seeing Ashlee she was informed by Ms Kartinyeri at Louise Place that
the situation was deteriorating. It was likely that Ashlee would be asked to leave
because Ashlee had broken the curfew and that her relationship with the staff had
deteriorated. Following this discussion Ms Morris attended Ashlee’s unit. Ashlee
was not happy about the fact that Ms Morris had met with Ms Kartinyeri without her
being present and accused Ms Morris of going behind her back. Ashlee became
extremely abusive and said that the situation was entirely the fault of the Louise Place
staff. She was extremely angry in her comments about Ms Kartinyeri and was calling
Ms Kartinyeri names and blaming her. The note of the visit states that:
‘Ashlee stated that we (Safe Babies) cannot take Chloe from her, that she won’t let us.
Ashlee stated that she has taken care of Chloe now for 2 years by herself and she has
never had Chloe taken from her (Ms Morris) stated that removing Chloe was not Safe
Babies’ intention and that the meeting was taking place so that Safe Babies can discuss
their concerns with Ashlee.’ 242
4.130. Ms Morris ended the visit because of its heated nature and the fact that Chloe was
exposed to it and she did not wish that to continue243. Ms Morris was asked why she
gave Ashlee a reassurance that it was not Strong Families Safe Babies’ intention to
remove Chloe. This was a concerning message to send in the circumstances as it is
providing a reassurance to Ashlee that never should have been provided at this
point244. Ms Morris was unable to give the Court a satisfactory explanation about this.
This was another example of the danger of relying on unqualified workers to make
decisions about case direction, particularly at times of crisis.
4.131. On 7 December 2009 Ms Vicky Lachlan from Louise Place informed Ms Morris that
Louise Place had given Ashlee seven days notice to leave. As a result of this Ashlee
and Chloe would again be homeless. Ms Morris was asked whether at that point she
240
Transcript, page 1303
241
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242
Exhibit C72, page 65
243
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244
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60
thought Chloe should be removed from Ashlee’s care and responded that she did
think that at particular moments245. She said:
‘I think – how can I put this? From someone who has not gone through the court
experience myself, and obviously hadn’t had anywhere near as much experience as
everyone else in the office, I need to explain myself. What I would want – the reality of
what is considered good enough parenting in a child protection system is very different
to my reality of what I think is good enough, and that is very sad. However, I had learnt
that workers’ ability to get certain cases through the system, the court system to remove
them was not an easy process. I know that I had had conversations with Leanne around
this, and we believed that it would not be a straightforward process, that it would
basically not go through the court.’ 246
4.132. Once again this assessment of the position at the time came from someone who was
only a social work student. Furthermore, at the time of giving evidence Ms Morris
had only had one further year of experience in child protection work as a fully
credentialed social worker and had not been in the field for four years. Yet the sense
of hopelessness in approaching the Youth Court comes out very clearly in this
passage of evidence. It is quite clear that the attitude of hopelessness in relation to
using the Court as a mechanism of securing Chloe’s protection had been imbued in
Ms Morris by others in the office. She had not had that experience firsthand herself,
so it must have come from others, and not only Ms Stewart.
4.133. In my opinion, particularly having regard to Exhibit C120 which is the
correspondence from the Senior Judge of the Youth Court, this negative picture of
hopelessness simply did not match with reality. In fact, it was completely
misinformed.
4.134. Ms Morris made further concessions about the inadequacy of her note keeping
practices247.
4.135. On the subject of the large amount of time that Chloe was spending in the Unley
Child Care Centre, Ms Morris conceded that the child care in this case was not being
used for the normal purpose envisaged by child care, namely to provide care to a child
while his or her mother or father is engaged in paid work. She said she acknowledged
that in this instance the child care was effectively to remove Chloe from Ashlee’s care
245
Transcript, page 1323
246
Transcript, page 1324 – the italics are mine
247
Transcript, page 1325
61
for a certain amount of time because it would be beneficial to Chloe to not be in her
care248.
4.136. Aftermath of Ashlee’s eviction from Louise Place – an overview
In the aftermath of Ashlee’s eviction from Louise Place she and Chloe were again
transient. I have already mentioned that in early January 2010 Ms Stewart had the
conversation with Ashlee in which she said that it was time to demonstrate a shift in
her behaviour or the matter would be escalated249. Then, on 15 January 2010, the
workers consulted the external consultant, Ms Claire Horgan, who made brief notes of
the conversation in relation to Chloe’s case250. On 20 January 2010 Ashlee and Chloe
commenced a tenancy at a private rental property in Mary Street, Unley. In all the
circumstances it was truly quite remarkable that they managed to obtain this private
tenancy. In any event, during this tenancy the difficulties continued. On 25 March
2010 it was learnt that ‘Martha’, another client of Families SA, was said to be moving
in with Ashlee at the Unley address. Martha had a history of drug use251. During this
period of time Chloe continued to attend at the Unley Child Care Centre and appeared
to be making developmental improvements. On 28 April 2010 Ashlee expressed the
view that she did not like the Unley area and wished to move back to Modbury252.
4.137. On 20 May 2010 the Strong Families Safe Babies team closed Chloe’s file. A case
closure summary was prepared at that time253. It features in later events and I will
attempt to summarise it. It contained a section headed ‘rationale for case closure’
which referred to signs of secure attachment between Ashlee and Chloe, Ashlee
obtaining private rental accommodation in January 2010 with Families SA’s
assistance, Chloe attending Unley Child Care Centre and showing developmental
improvements, Ashlee working as a waitress and cleaner and not apparently having
financial difficulties, Chloe spending every second weekend with carer Joy through
Time for Kids, Ashlee apparently having no face to face contact with the perpetrator
of the domestic violence of August 2009, risk assessment showing low to moderate
risk and, finally, no current child protection concerns and stability for a period of five
months. The case closure summary also contained a heading ‘worker assessment of
248
Transcript, page 1338
249
Exhibit C73, page 158
250
Transcript, page 2197, Exhibit C119
251
Exhibit C73, page 62
252
Exhibit C73, page 22
253
Exhibit C74, page 175
62
family’s current situation and infant safety’ which included mention of the fact that
Ashlee’s lease would expire at the end of July 2010 and she had been asked to leave
after that time254. Ashlee had stated that she wanted to return to the Modbury area
where her friends were located and Families SA had concerns about her return to the
influence of people who had influenced her negatively in the past. On the other hand,
Chloe was no longer a vulnerable infant being three years of age and having
communication skills. Furthermore, Chloe’s attendance at child care consistently is a
positive feature, but there is concern that this might cease when she and Ashlee are
required to leave their current residence.
4.138. On this rather tenuous note the case closure summary sought to justify the decision to
close the case.
4.139. On 18 June 2010 there was a further notification to CARL concerning Ashlee’s poor
behaviour and Chloe’s health.
4.140. By 20 July 2010 Ashlee had moved to another residence in Unley. During this
tenancy the situation continued pretty much as it had previously. On 25 August 2010
Joy Rann from Time for Kids contacted that organisation in relation to concerns for
Chloe’s wellbeing255. On 29 December 2010 there was a notification to CARL to the
effect that Chloe was being left in the care of people other than her mother and that
Ashlee was using drugs again and bragging about earning $900 at night working as a
cleaner256. On 30 December 2010 Ashlee contacted Housing SA saying that she
needed a house as she was about to be evicted. Ashlee and Chloe were then homeless
for an extended period. On 11 January 2011 Ms Rann contacted Time for Kids to
advise that Ashlee and Chloe were moving to Queensland. Families SA reopened the
file to investigate the notification of 29 December 2010257. On 18 January 2011 Ms
Rann rang Time for Kids again and informed them that Ashlee’s previous house was
left in a filthy state. There was a further notification to CARL about concerns that
Chloe had not been attending the Unley Child Care Centre and Ashlee was working
nights and leaving Chloe with other people258. On 21 January 2011 Families SA
workers attended to conduct a home visit at Ashlee and Chloe’s temporary residence
254
This is hardly an encouraging sign one would have thought
255
Exhibit C98, page 22
256
Exhibit C91
257
Exhibit C74, page 141
258
Exhibit C91
63
to investigate the notifications of late December 2010 and early January 2011259. On
23 January 2011 Ashlee contacted Families SA and requested crisis
accommodation260. On 24 January 2011 Families SA made a decision not to confirm
abuse in response to the notifications and to cease involvement with Chloe’s matter.
However, on 28 January 2011 there was a further notification to CARL on the basis
that Ashlee had been evicted from her residence. On 10 March 2011 Ashlee and
Chloe moved into an address at Royal Park with Ms Behsmann, who gave evidence at
the Inquest. Her evidence was that the house was not a tidy place261. On 8 June 2011
there was a further notification to CARL in which concerns were expressed about
drug use, the unkempt state of the house and Ashlee working as a prostitute. A
number of notifiers were involved with that notification. On 26 July 2011 the
organisation Time for Kids rang Ms Rann and advised that the Woodville office of
Families SA had advised that they would not be going to check on Chloe, despite the
notifications. On 25 August 2011 Families SA reopened Chloe’s file and conducted a
visit to the Royal Park address. Ashlee admitted to smoking cannabis262. The workers
involved in this visit told Ashlee that they would most likely not be confirming the
notifications.
4.141. On or about 2 December 2011 Ashlee and Chloe moved into McPartland’s address in
Ingle Farm. This was the last residence that Chloe lived in. On 16 December 2011
Time for Kids contacted Ms Rann and advised that Ashlee no longer wanted her to be
involved with Chloe263.
4.142. Families SA actions in 2010-2011
It is now necessary for me to return in the narrative to the end of 2009 and 2010 in
order to examine what occurred with Families SA during that period in relation to
Chloe. In late 2009 and early 2010 both Ms Stewart and Ms Morris had told Ashlee
that her case was being considered by ‘others’ in Families SA and that she needed to
make some major changes if she was to continue to have Chloe in her care. After
Ashlee was evicted from Louise Place, Families SA did not take any particular steps.
No action was taken to protect Chloe at that time. I have already mentioned that Ms
Stewart had a conversation with Ashlee on 7 January 2010 about making a
259
Exhibit C74, page 128
260
Exhibit C91, page 48
261
Transcript, pages 193-194
262
Exhibit C74, page 63
263
Exhibit C98, page 79
64
fundamental shift in her behaviour and putting Chloe’s needs before her own. There
is nothing in the various files of Families SA to explain what overall strategy was
being enacted in the holding of that conversation. What was it that caused Ms Stewart
to have that conversation at that time? The key decision points and strategies that one
would expect to find in the files are never there, and this is a further instance of the
absence of a record of the adoption of a new strategy.
4.143. It is clear that Claire Horgan, a principal social worker at Families SA, had been
consulted about the strategy to implement at this time. However, the evidence
showed that Ms Horgan was not consulted until 15 January 2010. Ms Horgan made a
written note of this264 in which she briefly noted the case of Chloe Valentine who was
2½ years old, that the mother was 18 years old and had not been ‘using’ for two years,
there was transience and the mother was stuck in adolescence but there was a secure
attachment. Reference is made to a family care meeting and to timeframes and clear
expectations.
4.144. Ms Horgan said this was the information that was given to her by the workers. The
reference to a family care meeting is a reference to a formal family care meeting
convened under section 27 of the Act265. Ms Horgan thought that she would have
spoken to Ms Stewart about these things on 15 January 2010.
4.145. That note of what Ms Stewart told Ms Horgan contains the barest of detail. It is
inaccurate in suggesting that Ashlee had not been ‘using’266 for two years. Clearly
Ashlee had been using drugs far more recently than that. The reference to a secure
attachment is an optimistic reflection of the true state of affairs. Ms Horgan said that
the note reflected what she had been told, and if she had been told more the note
would have reflected that267. Ms Horgan said that if she had been given a fuller
picture of the history of the case she would have asked more questions, particularly
about the drug and alcohol history268 . In any event, this was clearly the very scantest
of consultations. Furthermore, it appeared that the decision to suggest to Ashlee that
some kind of crisis point had been reached, had already been made and acted on.
Ms Horgan was not consulted until after that had occurred. I agree with Ms Kereru’s
submission that it is not surprising that Ms Horgan agreed with the plan on the brief
264
Exhibit C119
265
Exhibit C73, page 158
266
I take this to be a reference to the use of illicit drugs
267
Transcript, page 2204
268
Transcript, page 2206
65
and benign history that was conveyed to her. What is also clear is that no family care
meeting was ever arranged.
4.146. As I have said, in early 2010 Ashlee managed to secure private rental accommodation
and Chloe was secured in childcare four days per week at the Unley Child Care
Centre and was attending respite with Ms Rann every second weekend. There was
also another Time for Kids volunteer involved in her life at that time, a lady by the
name of Fereshthe Agahi-Pizarro. Furthermore, Chloe was frequently in the care of
others such as Ms Benyk and Ms Wallis.
4.147. I consider that a link can be drawn between the stern words of Ms Stewart with
Ashlee on 7 January 2010, and the six month timeframe she gave Ashlee at that time
to fix things, and the sudden improvement in Ashlee’s functioning for the next few
months. The team at Strong Families Safe Babies were reassured by the apparent
improvement in Ashlee’s ability to maintain a barely adequate level of parenting and
closed their file on 4 June 2010. The case closure summary269 that has been
mentioned earlier, referred to certain protective factors in the rationale for closing the
case. The protective factors included the fact that Chloe had regular contact with
carers through childcare at the Unley Child Care Centre and with the Time for Kids
carer, Ms Rann. It also noted that Ashlee was not currently in a relationship and
therefore domestic violence was not a risk factor at that time.
4.148. On 18 June 2010 a notification was made to CARL by a friend of Ashlee’s who
wished to remain anonymous270. The concerns that were expressed were that Chloe
was always sick and not properly medicated, that Ashlee got angry if any concerns
about her were raised by the notifier, that Chloe was dirty and smelly and that
marijuana and cigarettes were smoked in the house. Mention was also made of the
fact that Ashlee was earning a lot of money all of a sudden with a suggestion that she
might be breaking the law. That outcome of that intake was ‘closed no action’271.
The closure occurred on 29 September 2010.
4.149. On 29 December 2010 a further notification was made to CARL, this time by Lesley
Benyk and Ms Fick, the director of the Unley Child Care Centre. These concerns
were firstly that Chloe was left with various people for 50% of the time, that Ashlee
269
Exhibit C74, page 175
270
Exhibit C74, page 159
271
Exhibit C74
66
was working as a cleaner but obtaining $900 per night for it, her physical appearance
had deteriorated, allegedly due to drug use, marijuana was often consumed near Chloe
and Chloe was habitually very dirty and hungry and never wanted to return to her
mother. The concerns from Ms Fick were that Chloe had not attended childcare for
some time and had regressed in her toilet training. She also made mention of the fact
that Ashlee was working nights and leaving Chloe with others and was said to be
earning $900 per night.
4.150. This intake was investigated. The persons involved were Craig Rainsford who was a
social worker at Families SA at that time, Anna Clarke who was a senior social
worker who worked with Mr Rainsford on this case and Trevor Bailey who was the
supervisor for Ms Clarke and Mr Rainsford.
4.151. Each of these three Families SA employees gave evidence. Mr Rainsford said that he
got the case to investigate and that he was to contact the notifier and contact the
childcare centre and then address the concerns with Ashlee. Mr Rainsford admitted
that he did not call the notifier, Lesley Benyk, and said he did not know why he failed
to do that and acknowledged that he should have. He said that at that time he had
only been a social worker for eight weeks. He did however call Ms Fick from the
Unley Child Care Centre and spoke to her to obtain some background. He also spoke
to Ms Morris to obtain some further background from her about her time with Ashlee
and Chloe. He acknowledged that he did not speak to anyone from Time for Kids and
that he should have done so.
4.152. On 21 January 2011 he conducted a home visit with Ms Clarke to the address he had
been given. As it happened, that address was the home of Lesley Benyk who was one
of the notifiers. Mr Rainsford said that this was one of the first cases that he worked
on. He said that it was clear to him that the address of the premises was the address of
one of the notifiers. Despite this he did not speak to Lesley Benyk, although he
remembered Ashlee asking other people in the home about who might have made a
notification.
4.153. Upon Mr Rainsford and Ms Clarke arriving at the home, Ashlee took them out into
the backyard. Chloe was around the yard and was playing. Mr Rainsford could look
through glass doors at the back of the house and could see people inside the house.
He did not ask Ashlee about why she was now living at that address and not at the
67
previous Unley address she had been living at. He acknowledged that he did not ask
Ashlee about the nature of her work and he put this down to a lack of experience. He
also did not question Ashlee about Chloe’s failure to attend at the Unley Child Care
Centre.
4.154. Mr Rainsford said that he did however address the subject of drug use which Ashlee
denied. He did not ask to see Chloe’s bedroom and could not explain why not.
Furthermore, and quite remarkably, he did not question Chloe. He acknowledged that
at 3½ years she was old enough to be spoken to, but agreed that they did not speak to
her beyond some brief greeting.
4.155. For her part, Ms Clarke gave the following account of the visit. She said that she
could recall whether she made the connection that the address they were attending
was the address of the notifier. She said she could not recall because this is one of
dozens of cases that she has done. She said that a woman came to the door and was
initially hostile but then let the workers in. This was Ashlee. Ms Clarke said that
Chloe appeared happy, clean and healthy and was playing in the vicinity of her
mother. Ms Clarke was unable to recall whether Chloe spoke, nor whether she spoke
to Chloe. She could not remember if they asked about Chloe not attending childcare.
She assumed that she and Mr Rainsford asked about the nature of Ashlee’s work but
acknowledged that there was no note to that effect. In my opinion Mr Rainsford’s
recollection is the better in relation to this meeting. It is plain that no attempt was
made to challenge Ashlee about the nature of her work.
4.156. Ms Clarke said that she informed Ashlee at the end of the visit that there would most
likely be no need for further Families SA action, because that was the conclusion she
reached during the visit. Ms Clarke said that she did not know why Lesley Benyk
was not spoken to. When asked if she looked in the bedrooms at the house she said
that they did not because no concerns had been expressed about the bedrooms.
4.157. Mr Rainsford said that he recalled Ms Clarke telling Ashlee that there would be no
need for further Families SA involvement. He said that at the time he agreed with the
assessment. In effect it was enough that they were able to see Chloe and that she
seemed to be well. Mr Rainsford agreed that the investigation was substandard. He
acknowledged that he was not in a position to assess the bonding and attachment
between Ashlee and Chloe and he agreed that that was the most important thing to
68
observe. Having had a further four years of experience at the time of giving evidence,
he acknowledged that the workers could have done better.
4.158. Mr Bailey also gave evidence about this event. He acknowledged that the failure to
contact Lesley Benyk and speak to her to gather more information was ‘an oversight’.
However, he did not agree that it was a serious deficit in the investigation. It was
Mr Bailey’s view that ‘some elements were overlooked’ by the investigation and that
there were some oversights but that he did not believe that the outcome would have
been significantly different if more questions had been asked because he did believe
that Chloe was in serious danger at the time. He said that he did not think there was
anything else they would have done at the time, even if they had conducted a
thorough investigation.
4.159. In my opinion this event was very poorly handled. To describe the event as an
investigation is to glorify it with a title that it does not deserve. Mr Rainsford’s record
of the visit and his assessment of the outcome is an appalling document272. The
document suggests that the social workers observed Chloe as being a very happy and
well cared for child. When Ms Clarke was asked about that she acknowledged that
she might not have phrased it that way. The document states that Chloe attends the
Unley Child Care Centre five days per week. Of course this is inaccurate because
Ms Fick had already informed Families SA as part of the original notification that she
was concerned that Chloe was not attending. This assertion is completely wrong and
Mr Rainsford acknowledged that it was wrong when giving evidence.
4.160. The document went on to say that Ashlee appeared to be a loving mother and showed
insight into her previous involvement with Families SA. The document says:
‘Social workers were unable to observe Ashlee offering Chloe any emotional warmth as
during the home visit Ashlee was very agitated and angry at Families SA’s involvement.
For this same reason, social workers were unable to observe the bonding between Chloe
and Ashlee, however when speaking to SFSB, social workers detailed positive
attachment and bonding towards the end of their involvement.’ 273
4.161. That summary of the visit is blatantly wrong. The entire exercise miscarried. All of
the protective factors that had been identified in the case closure summary by Strong
Families Safe Babies in May 2010274 had now ceased with the exception of Ms Rann’s
272
Exhibit C74, page 125
273
Exhibit C74, page 125
274
Exhibit C74, page 175
69
involvement. Chloe no longer had stable accommodation and was no longer
attending the Unley Child Care Centre. Her development had regressed and Ashlee’s
behaviour was concerning.
4.162. To his credit Mr Rainsford acknowledged that he was inexperienced and that the
investigation was substandard. However, Ms Clarke adopted a very defensive attitude
in the witness box. It did her no credit. She deflected questioning by saying this was
one of many cases that she had dealt with. Much to his discredit Mr Bailey suggested
that the deficiencies in the investigation were mere oversights and that a proper
investigation would not have changed anything. In my opinion he is completely
wrong. Any competent investigation at this point would have revealed that something
was amiss. This represents another lost opportunity in a long history of lost
opportunities.
4.163. A further notification was made by Ms Fick on 28 January 2011. Ms Fick was
concerned that Chloe might become homeless and that she did not have any stability.
This notification was closed the same day as a notifier only concern. On 22 May
2011 a notification was made to CARL by an anonymous notifier. This notification
was that Ashlee did not have a washing machine and that Chloe’s clothes were dirty
and smelt. The notifier said that Ashlee worked in a brothel and would leave Chloe
with anyone to look after her. Furthermore, that Ashlee called Chloe a c*** and fed
her junk food. This notification was closed the same day and classified as a notifier
only concern.
4.164. The last notification to CARL that was actually investigated was made on 8 June
2011. The principal investigator was Tara Liston who was a social worker at Families
SA. The notification actually included three notifications, one from Ms Rann, one
from Ms Benyk and one from Lucy Seppelt from Time for Kids. Ms Rann’s concerns
included that she believed that Ashlee was working as a prostitute, that Chloe was
smelly and her hair was beginning to matt, that two months previously Ms Rann had
seen faeces scraped up the wall of the toilet in the house and the bowl of the toilet
being almost black, that there were sex toys on the mother’s bed in plain sight of the
child and that Chloe became increasingly upset when having to return to her mother.
She said that three weeks previously they had had no electricity and that there were
candles on the floor which were a hazard to Chloe. She said that the mother was
considered to be intoxicated or on drugs. Ms Benyk’s concerns were that Ashlee was
70
verbally abusive to Chloe, that she smoked marijuana around Chloe, that she had
made a Facebook entry that she had fallen asleep and left Chloe unsupervised and this
was a regular event. Ms Benyk said that the home was disgusting with food, bongs,
marijuana, scissors and cigarette lighters everywhere. Clothes were washed in the
bath, junk food was all that Chloe ate, there was pornographic material in the home
and Ashlee was talking about resuming her relationship with Dylan Hindle who had
recently been released from prison. Chloe chants the words ‘I want a horny daddy’
and Ashlee is suspected of prostitution.
4.165. Ms Seppelt’s notification was that there had been faeces on the walls, but at the next
visit it had been cleaned off. Ms Seppelt had discussed further the concerns expressed
by Ms Rann about the potential use of amphetamines, involvement in prostitution and
Chloe being upset when she was returned to Ashlee.
4.166. Ms Liston said that she conducted an investigation in relation to these concerns.
Ms Liston did not speak to Ms Rann but contented herself with speaking only to
Ms Seppelt. Ms Seppelt’s information had all come from Ms Rann in any event275.
Ms Liston could not say why she did not speak to Ms Rann and acknowledged that it
might possibly have been preferable to have done so. She said that she did not
contact the Strong Families Safe Babies team but was content to rely on their case
summary from May 2010. She did not consider contacting Ms Benyk and did not
know why. She said that she had a heavy workload at the time. She said that in
comparison to the other cases she was dealing with, Chloe’s case was not as
significant. In any event, Ms Liston conducted a home visit. She noted that Chloe
was clean, her hair was not matted and there was a washing machine that was
working. She said that Ashlee and Chloe engaged very well with one another and that
Chloe showed no sign of fear or reserve. The fridge contained food and Chloe’s room
appeared to be clean and orderly. She said there were toys in the house. Ms Liston
took the time to speak to Chloe and asked her to show Ms Liston her room, asked
what was her favourite toy and so on. She said that Chloe did not appear scared or
neglected and was happy and laughing. As a result of this visit this notification was
also closed with no further action.
4.167. Ms Liston had one further involvement in the case and that was on 8 December 2011.
She received a phone call from a staff member at Time for Kids who had contacted
275
Ms Seppelt was working in the Time for Kids office and did not have face to face contact with Chloe and Ashlee
71
Ashlee who had answered the phone and sounded disoriented. Ashlee had responded
to the caller identifying themselves as coming from Time for Kids by saying that she
did not know what Time for Kids was. Ms Liston said she would have discussed the
call with someone but did not recall who.
4.168. That was Families SA last involvement before Chloe’s death.
4.169. The evidence of Belinda Valentine
Belinda Valentine said that she is the mother of Ashlee Polkinghorne and was married
to Alan Polkinghorne, but has since remarried. She works as a face painter and this
brings her into contact with children. She works at major Royal Shows around
Australia and has had the necessary police checks to permit her to work closely with
children in that occupation.
4.170. Ms Valentine said that Ashlee had a good childhood and did very well in primary
school. Following Ms Valentine’s divorce from Mr Polkinghorne in 2003 Ashlee
moved in with her mother but soon wanted to go back to her father’s home. Ms
Valentine said that from the second half of year 7 and in the first couple of years of
high school Ashlee became more and more disruptive. There was a family meeting
involving Ms Valentine, her second husband, Ashlee and Ashlee’s father because
Ashlee was not attending school and needed to be brought into line. Ms Valentine
said that they entered into a ‘contract’ with Ashlee to get her to live with Ms
Valentine and her husband. This arrangement was unsuccessful and Ashlee returned
to live with her father. Ms Valentine became aware that Ashlee was using alcohol
and cannabis because Ashlee bragged to her about it. Ms Valentine said that soon
after Mr Polkinghorne commenced a new relationship Ashlee had to leave his home,
but was not prepared to come and live with Ms Valentine. Ms Valentine said that
Ashlee would not obey any rules imposed upon her by her parents or others and that
she burnt her bridges wherever she went. For some time she was couch surfing and
was always asking for money. Ms Valentine was reluctant to give her money because
she knew that Ashlee was likely to spend it on drugs and alcohol.
4.171. When Ashlee became pregnant Ms Valentine spoke to her about her future and how
she would cope with a child. Ms Valentine suggested that Ashlee consider a
termination, but Ashlee refused to do so and was angry at the suggestion. Ashlee told
Ms Valentine that she wanted someone to love her. However Ms Valentine
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commented that Ashlee’s idea of love was that if you did not give her what she
wanted, you did not love her. Ashlee would frighten Ms Valentine’s little boys with
her bad behaviour and that was a source of concern to Ms Valentine if Ashlee were to
live with her. At a fairly early stage Ms Valentine would have been prepared for
Ashlee to live with her provided that she behaved according to Ms Valentine’s rules,
however there was no prospect that Ashlee would do that. Ms Valentine said that she
made efforts to find an appropriate place for Ashlee to live and consideration was
given to Louise Place but unfortunately there were no vacancies there and Ashlee was
placed on a waiting list.
4.172. Ms Valentine said that Chloe was born in July 2007 and that she was present for the
birth. Ashlee did not want Chloe to have the surname Polkinghorne and that is why
she chose the surname Valentine for Chloe. Once Families SA became involved
Ms Valentine was aware of the various workers, including Ms Daniel, Ms Stewart and
Ms Morris. She was given a telephone number by Ms Francou to call and as a result
of this she never contacted CARL because she had what she thought was a direct line
to the social workers.
4.173. Ms Valentine said she felt that the Families SA workers did not take her concerns
seriously. She said that she never got any feedback. She was never asked for her
home to be checked with a view to establishing its suitability for Chloe to live in. She
was never asked for her extended family’s contact details.
4.174. When Ashlee moved to the Hope Valley unit provided by the Salvation Army she
needed a deposit. Ms Valentine gave her the necessary amount of $1,000 so that she
would have accommodation. Ms Valentine once again tried to impose some
accountability on Ashlee by requiring her to enter into a contract in relation to the
$1,000. The contract was for her to pay the money back when she received her baby
bonus and that Ashlee was also to attend a young mother’s program known as the
Green Room276. In the result, Ashlee never complied with the terms of that contract.
Ms Valentine said that Ashlee would have been welcome to live with her and her
family, but Ashlee was not prepared to comply with their rules and they were not
prepared to have her unless she did so. Hence the Salvation Army unit.
276
The contract is Exhibit C1d
73
4.175. Soon after Chloe’s birth Ashlee seemed excited to have a baby. When Chloe was still
very young Ms Valentine saw that Ashlee was feeding her with water because she
said she did not have any formula. She did not have a steriliser and appropriate
nappies so Ms Valentine bought those things for her at Tea Tree Plaza. Ashlee
wanted the receipt but Ms Valentine refused to give it to her. Previously when Ashlee
had been given receipts she had used them to return the goods for a refund and then
spent the money on alcohol. Ms Valentine said that it reached the point that when she
bought items for Chloe she would give them to Chloe and cut the tags off so that
Ashlee would be unable to return them.
4.176. Ms Valentine said that Ashlee had never lived in dirty circumstances. When she
moved into the unit Ms Valentine tried to teach her – again – how to do the things that
were necessary and to maintain a reasonable home, even though Ashlee had been
shown these things by her before. Ms Valentine said she showed Ashlee how to use
the laundry products, including separating whites and so on. Ms Valentine did this a
few times but then it became apparent that Ashlee was waiting for her to come rather
than doing the work herself. Ms Valentine told Ashlee it was her responsibility and
that she needed to be responsible for her actions. Ashlee became furious when Ms
Valentine said these things and spoke in a violent manner towards her.
4.177. Ms Valentine said that when Ashlee took drugs her behaviour became very emotional
and erratic. Ms Valentine said that the Salvation Army unit became a ‘party house’
and that Ashlee was very thin and haggard. At first it was difficult to tell if this was
due to drugs or the fact that Ashlee was a new mother. Ms Valentine thought that
Ashlee was using cannabis and spoke to her about it. She also contacted the Adelaide
Clinic to see if Ashlee could be admitted there. Ashlee simply laughed at Ms
Valentine saying that it was only cannabis and that she should get over it. Ms
Valentine told Ashlee that it was illegal and that it could change her state of mind.
She wanted Ashlee to get counselling about drugs but Ashlee thought the proposition
was ridiculous.
4.178. Ms Valentine talked about the occasion when her son’s partner, Kate Wallis, recorded
a telephone call from Ashlee which I have referred to earlier in this finding. It is
sufficient to say that Ms Valentine found the call very distressing and was concerned.
She told her son, Jake, to make a report to Families SA about the tape. Subsequently
she spoke to Ms Francou who told her that Families SA were in possession of the
74
recording. Ms Valentine said that Ms Francou told her that even if Ashlee was a drug
addict, it did not mean that she could not look after a child. Ms Francou gave Ms
Valentine a telephone number to call if she had concerns.
4.179. Subsequently Ms Valentine became aware that Lagden was living at the unit. She
told Ashlee that this could put her lease in jeopardy and also that Lagden was a drug
user. Ms Valentine said that Ashlee asked her husband to attend the unit and patch
walls because Lagden had punched them. Ms Valentine spoke to Ashlee about
domestic violence, but Ashlee denied that domestic violence was an issue and said
that both she and Lagden were angry at the same time.
4.180. Ms Valentine said that Ashlee hated what she described as Families SA’s
‘interference’. Ashlee saw herself as a good mother and said that Families SA should
mind their own business. Ms Valentine said that when Ashlee was evicted from the
Salvation Army unit she assisted her to move out. She said that she took some of
Ashlee’s possessions to a storage unit. She said that Ms Daniel was present at the unit
on that occasion and Ms Valentine introduced herself. She said that Ms Daniel was
the only social worker from Families SA whom she met277 and Ms Valentine only met
her on that one day. She told Ms Daniel about the unhygienic circumstances and the
drug use and said that Chloe should be removed and that she would be prepared to
have Chloe. Ms Valentine said that Ms Daniel told her that she did not have the
authority but would tell Ms Stewart. Ms Valentine also told Ms Daniel about the
bond money and how it ought not to go to Ashlee. She was concerned that Ashlee
was not managing her money well and that if she came into an amount of $1,000 she
would spend it on drugs. She proposed that the bond money might go to Ashlee in
instalments, or go to her, or go towards a further bond for the next house. However,
the Families SA staff made it very clear that Ashlee was entitled to receive the bond
money back. Ms Valentine was never repaid that amount by Ashlee.
4.181. Ms Valentine said that when Chloe was about one year old Ashlee was couch surfing.
Ms Valentine said that Chloe was filthy when she saw her and did not seem well fed.
She had Chloe stay with her from time to time but no items came with her. Ms
Valentine said that Chloe was not happy to go back to Ashlee and she reported this to
Ms Stewart at Families SA. She did not report it to CARL because she was reporting
it directly to the senior social worker. Ms Valentine said that there was an episode
277
Ms Valentine was not then aware that Ms Daniel was a family support worker and not a social worker
75
when she and her husband were interstate and Ashlee came to her house, using a spare
key that was hidden in the garden278 and stole $5,000 that was in the house. Ashlee
denied that it was she and Ms Valentine was unable to prove that it was Ashlee.
4.182. Ms Valentine was referred to a conversation she had with Ms Daniel on 28 August
2008 when she told Ms Daniel that she had had Chloe overnight. On this occasion
Ms Valentine expressed her concerns about Ashlee’s couch surfing and about the
condition of one of the premises Ashlee was staying at where there were water bongs.
Ms Valentine suggested to Ashlee that Chloe might come and live with her for awhile
but Ashlee became hysterical and violent in her language. Ms Valentine told Ashlee
that she would ring Families SA but Ashlee laughed and said that Families SA were a
joke. Ashlee said that she would clean the place up and by the time Families SA got
there they would see nothing wrong and conclude that Ms Valentine was a malicious
liar.
4.183. Ms Valentine said that she regularly contacted Families SA but that over time she
thought that her concerns were not being taken seriously. She said that she ‘wasn’t
heard’279.
4.184. Ms Valentine referred to an occasion in November 2008 when Ashlee went to live at
Taperoo. At about this time Ms Valentine received a call in the early hours of one
morning from Crisis Care. Ms Valentine said she was very confused because she was
asleep at home and her husband was away. She had the two boys who were then four
and eight who were asleep in the house. Ms Valentine said that the Crisis Care
worker said she needed to come and collect Chloe who had been left with a 15 year
old because Ashlee had become paralytic and wandered off. The 15 year old lived in
the Wynn Vale area, a place Ms Valentine had never heard of. She was being asked
to pick up Chloe and return her to Ashlee the next day. The details of this
conversation are dealt with under the evidence of Ms Heading. I do no more than
simply mention it here. For some time after this episode Ms Valentine did not hear
from Ashlee and Chloe. Ashlee would not answer the phone.
4.185. Ms Valentine said that on quite a few occasions when she contacted Families SA they
said they could not give her information because of Ashlee’s privacy. Ms Valentine
278
Ashlee knew where it was hidden
279
Transcript, page 2317
76
said when she responded that she was calling about Chloe’s safety, Families SA still
told her that it was a matter of Ashlee’s privacy. Ms Valentine said this happened
many times.
4.186. Ms Valentine said that she was always as supportive as she could be without
accepting Ashlee’s excuses280. She said she really wanted Ashlee to go to counselling
but that Ashlee blamed everyone else for her choices. She said that Ashlee was very
strong willed and she simply could not force her to accept counselling. She attempted
to talk to Ashlee about reality and responsibility but Ashlee did not want a bar of it.
4.187. Ms Valentine referred to an incident in August 2009 when Ashlee called her from her
new house in Rostrevor to say that she had been beaten up by her boyfriend and
wanted Ms Valentine to come to the house. Ashlee told Ms Valentine that the person
who had beaten her was called Foetus (this is because he had a tattoo with a jar
containing a foetus on his back). Other evidence has revealed this person’s identity to
be Dylan Hindle, although that was not known to Ms Valentine at the time.
Ms Valentine went straight to the house. She said that Chloe was in the lounge room
cowering in a corner and Ashlee was in the bedroom with the door closed.
Ms Valentine picked Chloe up and she was very frightened. Chloe clung on to
Ms Valentine and buried her head into Ms Valentine’s arms281. Ms Valentine’s
husband walked over and at first Chloe was frightened of him but after some time she
allowed him to hold her. Ms Valentine then went to Ashlee who was curled on her
bed and was hurt and frightened. She appeared to have injuries to her wrist and ribs.
The room was disgusting. Ashlee said she had only been there a few days.
Ms Valentine noticed drug paraphernalia and told Ashlee to call the police. Ashlee
refused and said that if Ms Valentine called the police she would never see Chloe
again. Ms Valentine told Ashlee to leave the place immediately. She helped her to
get some belongings and reminded her to get some of Chloe’s clothes as well. Ashlee
started collecting some of her drug paraphernalia and Ms Valentine said that she was
not to bring it. At that point Ashlee told Ms Valentine to ‘fuck off’. Ms Valentine
talked about taking Ashlee to a domestic violence shelter so that she could get
counselling but Ashlee thought that was ridiculous. Ashlee became angry and rang
her friend Nicky Behsmann. Ms Valentine said that she now wished that she had rung
280
Transcript, page 2330
281
Transcript, page 2333
77
the police at the time but instead rang Families SA282. Ashlee screamed at her not to
contact Families SA, however Ms Valentine did so and said that she put the call on
loudspeaker so that Ashlee could hear. Ms Valentine said that she spoke to Ms
Stewart about the situation. Ms Stewart told Ms Valentine that she could not tell
Ashlee where to live and that she (Ms Valentine) had no right to take Chloe away
(Ms Valentine had said that she wanted to take Chloe to her house)283. Ms Stewart
was aware that Ashlee was there and was listening. Ms Valentine said that Ashlee
was laughing at her so she reminded Ms Stewart that Ashlee was listening.
Ms Valentine told Ms Stewart that she wished to have Chloe in her care and that if
she ever saw Ashlee with this man again she would go to court to get Chloe’s
custody. Ms Stewart told Ms Valentine that she would not help. In the meantime
Ashlee took Chloe and went with Ms Behsmann. Ms Valentine said that she asked
Ms Stewart to put her through to her supervisor but Ms Stewart responded by saying
that she was the supervisor and any call would come back to her. Ms Valentine said
that her husband was present during this telephone conversation and because it was on
loudspeaker he was able to listen to it.
4.188. Following Ms Valentine’s evidence about her telephone call to Ms Stewart it was
necessary to recall Ms Stewart so that she could be questioned about that topic. Ms
Stewart’s evidence was that she denied that Ms Valentine had called her on 7 August
2009 as suggested. She believed that she would have recalled such a call. Ms Stewart
maintained her denial in the face of the evidence of Ms Valentine that the call had
been put on loud speaker so that Ashlee and Ms Valentine’s husband could hear it.
Ms Valentine’s assertion that she was told by Ms Stewart that she had no right to take
Chloe away from the situation was also put to Ms Stewart and she denied that she said
that. Ms Stewart acknowledged that she had failed to make casenotes in the past,
including about important matters. Ms Stewart contended that she was first told about
the episode when she learnt about it from an employee of Time for Kids.
4.189. It is true that there is no file note in the Families SA casenotes recording that
Ms Valentine made a phone call on 7 August 2009. However, there are many
omissions in the casenotes, including of important events. The fact that the matter is
not noted is not very persuasive either way. On the other hand, Ms Valentine has only
ever had one experience with the child protection system and would have every
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reason to have a clear recollection of the event. Furthermore, her version of the event
was supported by her husband, Steven Harvey, who corroborated her version of the
telephone call and said that he was present and heard the call. His version clearly was
that the call occurred on 7 August 2009. Ms Stewart has dealt with hundreds of child
protection cases. It would not be surprising if she had forgotten about something that
occurred in one of them, particularly when being asked to recollect the event more
than five years later. Having regard to all of the evidence I prefer the evidence of
Ms Valentine on this subject. However, it does not follow necessarily, and I do not
believe, that Ms Stewart deliberately lied to the Court. I consider it more likely that
she was mistaken and could no longer recall.
4.190. Ms Valentine said the next time she saw Chloe was at the Royal Adelaide Show in the
first week of September. Ms Valentine said that Chloe was with Ashlee and that they
came to Ms Valentine’s stall where she painted Chloe’s face. Ashlee asked for a large
amount of money and Ms Valentine refused. Ashlee started swearing and screaming,
and Chloe started crying and Ashlee took Chloe away.
4.191. Ms Valentine said that when Ashlee went to Louise Place with Chloe in late 2008,
Ms Valentine followed her progress there. Ms Valentine said that things started to
deteriorate with dirty nappies and food everywhere. She said that Chloe was at
childcare which she loved. Ms Valentine gave evidence of a dinner with Ashlee and
the rest of the family at Caffé Primo at Tea Tree Plaza. Ashlee started talking about
Louise Place and how she expected to be evicted because there were too many rules
and interference from the staff. Ashlee demanded that Ms Valentine assist her to find
private accommodation so that she could rid herself of the interference. Ashlee
wanted Ms Valentine to pay for her private rental but Ms Valentine refused and said
that Ashlee needed supported accommodation. She also said that Ashlee’s
environment was unsafe for Chloe and Ashlee. At this Ashlee became very angry and
called Ms Valentine a ‘fucking c***’ in the middle of the restaurant284.
4.192. Several days later Ms Valentine received a telephone call from Ms Morris of Families
SA asking her to take part in a family meeting. Ms Valentine said that it would not be
helpful given the recent argument she and Ashlee had had. Ms Morris told
Ms Valentine that Ashlee was on her last chance with Chloe and was very likely to be
evicted from Louise Place. She said that Families SA were looking at the best options
284
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for Chloe and that it was important that Families SA and others present a united front,
including Ms Valentine285. Ms Valentine thought that Families SA might support an
application for her to have Chloe. However, Ms Valentine then had a conversation
with Ms Stewart who said that the position of Families SA was not that Chloe would
come to Ms Valentine by herself, but with Ashlee. Ms Valentine said this was not
possible because Ashlee had no respect for the rules in her household and she had two
young boys who she wished to keep safe from Ashlee. Ms Valentine said that she
made it very clear to Ms Stewart that she would have Chloe, but not Ashlee286.
Ms Valentine said that she did not wish to be manipulated into a situation where she
had to have Ashlee in her home. She said that she loved Ashlee but that Ashlee was
dangerous to her young children, had no respect for anyone and was dangerous for
Chloe. Following this Ashlee was evicted from Louise Place. Ms Valentine said that
Families SA would not tell her where Ashlee and Chloe were at that point out of
respect for Ashlee’s privacy287.
4.193. Ms Valentine said that she next became aware that Ashlee was living in a rented
house in Unley. She said that during this time there were some good periods and
some bad periods. She said that Ashlee liked it when there was a new thing in her life
and that a new place would mean that things would go well for awhile but it would
not take long before they started to deteriorate. After some time Ms Valentine
thought that Ashlee was drinking heavily288. She referred to Chloe’s birthday party
when Ashlee was drunk at 11am. Ashlee had purchased a large ice cream cake for
Chloe and was singing happy birthday, but Chloe was not even in the room at the
time. Ms Valentine said that the whole event ended badly when Ashlee asked for
money. Ms Valentine asked Ashlee about how she was getting money and Ashlee
claimed to have a job as a cleaner. Ms Valentine said she was shocked at this because
she simply found it unbelievable that Ashlee would be a cleaner. She tried to ask for
details of the job but Ashlee was evasive289.
4.194. Ms Valentine soon found out from Ashlee’s peer group that Ashlee was in fact
working in a brothel as a prostitute290. Ms Valentine said that she felt hurt and
defeated and very sorry for Ashlee. She confronted Ashlee who denied it.
285
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286
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287
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288
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289
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290
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Ms Valentine became aware of a revealing photograph of Ashlee in a bikini wearing
boots on Facebook and this confirmed her suspicions. She spoke to Families SA
about her concerns as to the prostitution and Families SA confirmed that they were
already aware of it and were investigating291. Ms Valentine said that after this she had
less contact with Ashlee and Chloe. She said that they would occasionally meet in a
park. They found that from this period onwards when Ashlee had money of her own
she did not need to contact them. In the past when Ashlee had needed money she
would ask them for large sums in the order of $1,500 or $3,000, not smaller amounts.
She said that they did not give her cash because of her issues with drugs.
4.195. Ms Valentine referred to a later stage when Ashlee had moved into an address at
Royal Park and Chloe had got older. At this time Chloe’s speech had become better
thanks to her attendance at childcare. Once again it seemed that Ashlee had made a
new start and picked herself up a bit. However it did not last long. Ms Valentine had
less contact with Families SA during this period because she was working more and
had less contact with Chloe. Furthermore she had lost confidence in Families SA and
did not believe they would take any action in relation to her concerns292. In
October 2011 Ms Valentine received a telephone call from Ashlee who sounded
stoned and angry and claimed to be thinking of killing herself because her mother did
not care about her. Ashlee said that her then boyfriend would take Chloe when she
died. Ms Valentine said to Ashlee that if anything happened to her ever that she
would take Chloe. To this Ashlee said that Ms Valentine was a ‘fucking c***’.
During this conversation Ms Valentine was aware that Chloe was in the background.
Ms Valentine heard Chloe say to her mother words to the effect of ‘don’t talk to
nanna like that’. Ms Valentine then heard Ashlee say to Chloe words to the effect
‘you’re just like your nanna, you fucking c***’293. Ms Valentine felt the situation was
really escalating and spoke to Families SA.
4.196. Ms Valentine said that in late 2011 Ashlee had moved into an address at Ingle Farm
with McPartland. She said that after she became involved with McPartland, Ashlee
became markedly different. The house was extraordinarily clean and Ashlee was very
submissive towards McPartland. If Ms Valentine asked to see Chloe, Ashlee said that
she would have to check with McPartland first. Ms Valentine said that she and her
291
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292
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293
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81
husband took Chloe on a day trip to St Kilda and had a lovely day. She said that
Ashlee and McPartland knew that they were returning Chloe to the house and when
they arrived there were five couples there with Ashlee and McPartland. Ms Valentine
said the whole place was filled with cannabis smoke and she said that she would not
leave Chloe in this situation. Ashlee and McPartland laughed at her and said that they
would clean it up if she called the police and it would look like Ms Valentine had
made it up294. Ms Valentine said she did not call Families SA on this occasion
because they had not done anything about any of her previous reports. She said
towards the end of November Ms Valentine’s parents were visiting her from
interstate. After speaking with McPartland, Ashlee said that Ms Valentine would be
allowed to have Chloe at her house. During the visit Chloe was helping Ms Valentine
do the dishes. Chloe dropped a cup and became very distressed. Chloe cowered
away and was profusely apologetic. Ms Valentine looked at her and said that it was
okay. Ms Valentine’s father was in the kitchen too. He could clearly see how Chloe
was overacting to an everyday situation and so he came over and he himself picked up
a cup from the sink and dropped it on the ground. He said to Chloe that it was okay
and that it was just a cup and it did not matter. He picked Chloe up and said ‘all that
matters is you, that the silly old cup does not matter’. Chloe snuggled into him295.
Afterwards Ms Valentine’s father asked her what was going on in Chloe’s house that
resulted in her being so frightened of something so trivial.
4.197. Ms Valentine and her husband dropped Chloe off at Ashlee and McPartland’s house.
They went in and Chloe was clinging to Ms Valentine and was very uncomfortable
and clearly did not want to stay. She said words to the effect of ‘please don’t leave
me here with them’. Ashlee responded by saying ‘this is my child’ and then Ashlee
gave Chloe to McPartland. McPartland took Chloe to her room screaming. Ashlee
told Ms Valentine to go away and never come back. This was said in front of
Ms Valentine’s parents. Ms Valentine said that Ashlee had never been like that in
front of her parents before.
4.198. Ms Valentine contacted Families SA to inform them of this event. She did not recall
to whom she spoke but rang the usual telephone number. She mentioned also that
Ms Rann was no longer involved with Chloe, nor Krystal and Lesley Benyk and that
McPartland did not like the way they looked after Chloe. McPartland claimed that
294
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82
when Chloe came back from one of their houses she would not sleep properly.
McPartland also claimed that they were giving Chloe the wrong food. Ms Valentine
said that she felt that McPartland and Ashlee were isolating them from Chloe.
4.199. Ms Valentine said that on that weekend when Chloe stayed with she and her family,
Chloe slept in the same room as Ms Valentine’s son who was close to her age. Chloe
told the boy that she was frightened of McPartland. Ms Valentine’s son only told
Ms Valentine about that conversation after Chloe had died. Ms Valentine said that he
felt very guilty for not protecting Chloe.
4.200. Ms Valentine said that when she spoke to Families SA about her concerns they said
they would look into the matter. However she did not get any feedback and had no
further contact from them and has never heard from them since.
4.201. Ms Valentine said that after Chloe’s death she tried to speak to Families SA the
following Monday. She rang the Modbury office and asked to speak to the social
workers. She said that she wanted to tell them that she did not blame them for
Chloe’s death. However, she said that she was told that her call was inappropriate
and to never speak to Families SA again. Ms Valentine did not know whether a
notification had been made about the episode leading to Chloe’s death.
4.202. Ms Valentine has never since that time been called or contacted by Families SA.
They have never asked her about Ashlee’s background, nor sought evidence of
Ashlee’s drug use or anything else. Ms Valentine said that she believed that Chloe
was treated like a pawn by Ashlee to get what she wanted and that Ashlee had no
intention of stopping her drug taking and was merely interested in her own self
gratification.
4.203. Before leaving Ms Valentine’s evidence I refer again to what she said about the
episode when Chloe dropped the cup and reacted with disproportionate fear. This
incident was very reminiscent of an incident described by Ms Rann concerning Chloe
playing with Ms Rann’s iPad. On that occasion that Chloe spilt milk on the iPad and
was trembling in fear of the consequences. It was necessary for Ms Rann to provide
her with constant reassurance that it was merely an accident296. These two episodes,
observed by two women who had never met each other but were close to Chloe and
296
Refer to paragraph 7.35 of this finding
83
very interested in her welfare, suggest that the child was very fearful of what might
happen to her if she made the slightest mistake. They are a powerful indicator that
Chloe was used to being harshly punished for small transgressions. From her reaction
it would appear that she was used to such severe consequences that she would tremble
and cower in anticipation. This is suggestive of abuse and probably physical abuse.
It could have occurred nowhere other than in Ashlee Polkinghorne’s home at the
hands of either Ashlee herself or McPartland.
5. Conflict of interest
5.1. Social workers working with parents of young children, including such parents who
are themselves under 18 years, must act at all times in the interests of the child. They
must be trained to see that the interests of the child and an irresponsible parent are in
conflict. You cannot act in the best interests of both. Any attempt to do so will
inevitably lead to confusion and muddle headed thinking such as we have seen
throughout this Inquest.
5.2. There were many instances of this approach. At times it seemed that Chloe’s interests
had been forgotten completely while the focus was on Ashlee and her demands. A
process of appeasement was followed in their dealings with Ashlee, and the more
chances she was given, the more demanding and unreasonable she became. When a
firm line was taken – for example in January 2009 when she was told that ‘others’
were considering options for Chloe’s care, she modified her behaviour and improved
for a while, only to return to her normal substandard performance when she became
comfortable again.
5.3. I am firmly of the view that social workers must accept that the child’s best interests
can and do conflict with the parents’ sometimes. In some cases, such as that of Chloe
and Ashlee, they conflicted most, if not all of the time. It was not possible to act in a
way that was best for both of them. So Ashlee’s needs and interests had to give way
to Chloe’s. They must become the standard approach in dealing with these cases.
6. Families SA – workload issues and resources
6.1. The evidence of Families SA witnesses was peppered with remarks about their
workload. There were references to the ‘hopelessness’ of the magnitude of the task,
the lack of resources and the risk carried by staff in having to close cases without
84
action because all available staff were overburdened by their existing work297. These
passages of evidence were never challenged by counsel for the Department for
Education and Child Development. For example, counsel for the Department for
Education and Child Development had no questions of Bruce Johnstone, despite his
damning evidence about workload and the need to close 20 to 30 cases per week
without investigation.
6.2. In Mr Harrison’s evidence he cited resourcing as an issue in relation to Families SA
complying with section 20(2) of the Act298. Mr Harrison was asked by his own
counsel about resources in the context of tier 2 notifications not being acted upon and
he responded as follows:
‘… if you’re working as smart as you can, that would be the conclusion you would draw.
I’m not so sure that we’re working as smart as we can currently and that hence the
redesigned program is looking at 11 different components of our child protection system
internally to ensure that we have got the most efficient and effective aspects of
operations in each of those individual areas but through the system from start to finish as
best we possibly can. So I’m not so sure we have the most efficient system currently and
hence that’s why there is a lot of work going on in relation to the redesigned program.’ 299
Thus we have the staff coming along and giving evidence that they have an
overwhelming workload. On the other hand we have the chief executive suggesting
that additional resources may not be required because he is not convinced that the
existing resources are being used as efficiently and effectively as possible. See also
paragraph 9.17 of this finding where I note that Mr Kemp, who was recently a senior
executive in Families SA does not necessarily accept that existing resources are being
properly used. It seems to me that it is necessary that there be a proper assessment to
ascertain the most effective resource allocation method for Families SA. Mr Harrison
mentioned that work is being done on this. In my opinion that work should include as
a starting point a consideration of the volumes of work and what resource effort is
needed to carry out that work satisfactorily. There must be an ability to monitor
unfinished work. There must be a system to measure the performance of individuals
in the agency and the individual parts of the agency and there must be a reliable
system for reporting those measurements in a timely manner to managers right up to
the chief executive and I intend to recommend accordingly.
297
See generally the evidence of Bruce Johnstone, Carolyn Curtis and Janelle Morris
298
Refer to paragraph 13.2 of this finding
299
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6.3. Mr Harrison went on to say that the agency is currently considering what is the role
and function of a statutory child protection authority. He said:
‘Is it about investigation, assessment and response and removal or is it also about
investing and building strong families as well and hopefully minimising the necessity
and need to remove children from families.’ 300
I am concerned that Mr Harrison seems to be suggesting that Families SA ought to
invest more time and effort into building strong families to minimise the necessity to
remove children. The work of Dr Jeremy Sammut that I refer to later in this finding301
makes a very convincing case that relentless pursuit of efforts to support families that
are dysfunctional is damaging to children. Families SA needs to ask itself whether its
resources are best deployed in having workers such as Mr Ratsch, Ms Kidner and
Ms Daniel involved in the physical task of cleaning a filthy mess that has been created
by a dysfunctional 16 year old such as Ashlee Polkinghorne, or whether their time
would be better utilised in building a case to take to the Youth Court for an
investigation and assessment order requiring Ashlee to submit to regular drug testing.
6.4. It is relatively easy for a public sector worker to come to the Coroners Court and say
that they were overwhelmed with work when questioned about why they did not take
action on a particular occasion that seemed to be necessary. This Court often hears
that kind of response from public sector employees. The Court must be cautious
about accepting such claims in the absence of further information about whether the
work of the person concerned is being properly measured, and whether the person is
applying their efforts to the highest priority tasks. For example, the task of driving
Ashlee from one real estate agent appointment to another, and to assisting her in
cleaning her unit, not once but on a number of occasions, would seem to me to be a
lower order of priority than the task of properly recording key decisions in Families
SA notes. Or, in making the effort to properly investigate some of Ashlee’s more
unlikely claims by contacting all of the notifiers in relation to a particular notification,
and seeking out other sources of information. That kind of work would have a far
greater value in my opinion than carrying out menial tasks on Ashlee’s behalf.
300
Transcript, page 2516
301
Do Not Damage and Disturb: On Child Protection Failures and the Pressure on Out-of-Home Care in Australia (2011)
Sammut, Jeremy – ISBN 9781864322064 http://www.cis.org.au/images/stories/policy-monographs/pm-122.pdf
86
7. The perspective of the external agencies dealing with Ashlee – a radically
different perception
7.1. Throughout the evidence it was apparent that there was an immensely different
perception of Ashlee on the part of external services from that professed to be held by
the Families SA witnesses. This phenomenon was apparent as early as Ashlee’s
tenancy with Salvation Army at the Hope Valley unit. The perception of Katie
Lawson, her assigned Salvation Army support worker, was completely at odds with
the view of Ashlee taken by the workers at the time, particularly Mr Ratsch, and, to
her credit, to a lesser degree by Ms Kidner.
7.2. The experience with Port Youth Accommodation at Taperoo was a repeat of the
earlier experience. This time the Port Youth Accommodation worker was noted in the
Families SA’s file as having a clash of personality with Ashlee. The file notes were
written as if it was the clash of personality that one might see in a normal interaction
between two reasonable people. In fact, a moment’s consideration would show that
Ashlee was the common denominator in a series of disputes and it would be highly
unlikely that she was the ‘innocent’ party on every occasion but had the back luck to
encounter a series of service providers treating her unjustly. This very jarring contrast
between the Families SA perspective of Ashlee and the external service provider
perspective of Ashlee is well illustrated through the evidence of three witnesses who
were involved with Ashlee and Chloe in 2009/2010. They are Vicky Lachlan who
was the manager of Louise Place, Cassandra Fick who was the director of the Unley
Child Care Centre and Joy Rann who was the Time for Kids volunteer who provided
respite care for Chloe. Before leaving these introductory remarks I would also
observe that another group of people outside Families SA who were not external
service providers had a view of Ashlee that matched the view of the external service
providers. That group consisted of Ashlee’s family and friends, including particularly
her mother, Ms Valentine, and her friend and Chloe’s Godmother, Krystal Benyk.
7.3. Vicky Lachlan
Ms Lachlan was a very impressive witness. She was the manager at Louise Place for
5½ years. She said that Ashlee moved into Louise Place on 16 September 2009 and at
first she seemed willing to engage with Louise Place and their regime. She said that
soon however, Ashlee became agitated about their rules and the situation slowly
became worse. She said that there were occasions when Ashlee swore at the staff and
87
walked out of meetings, slamming the door so hard that the impact could be felt
through the building. Ms Lachlan’s assessment of Chloe was that she was quite
independent. She always tried to please her mother and did not get upset. Ms
Lachlan formed the view that this was probably because Chloe was used to her needs
not being met. Ms Lachlan said that she did not believe that Ashlee was able to learn
how to care for her child.
7.4. By early October the Louise Place staff requested a meeting about Ashlee breaking
their rules and being disrespectful to staff and other clients. The culmination of the
meeting was that Ashlee was offered one week’s probation.
7.5. Ms Lachlan remembered Janelle Morris, who it will be recalled was the social work
student who was primarily working with Ashlee and Chloe at that stage. Ms Lachlan
thought that Ms Morris was one of the social workers at Strong Families Safe Babies.
She did not recall having been told that Ms Morris was a social work student. She
said that at the Louise Place site, student social workers would not be allowed to work
on their own with clients and were required to have constant supervision. She said
that she most likely assumed that Ms Morris was qualified because she was working
one to one with Ashlee and that was how Louise Place operated.
7.6. Ms Lachlan said that Ashlee gradually became somewhat comfortable at Louise
Place. At first she kept her unit in reasonable condition. Ms Lachlan said that
Ashlee’s unit had been renovated shortly prior to her moving in. She said the unit
was really nice at that point.
7.7. Ms Lachlan said once Ashlee felt comfortable she appeared to think she did not need
to do anything that the Louise Place staff required and the situation deteriorated quite
quickly.
7.8. Ms Lachlan said that such negative behaviour as that shown by Ashlee in front of
Chloe, and the fact that Chloe’s needs were not being met by Ashlee was not being
seen by Ms Morris.
7.9. Ms Lachlan was asked to consider a Strong Families Safe Babies assessment of the
situation on 8 December 2009 when they spoke to Ashlee following her eviction from
Louise Place. At that time Ms Stewart had felt that Ashlee had made progress
according to the assessment. Ms Lachlan said that surprised her. She believed that
88
Families SA were not taking the whole picture into account. She said that Louise
Place staff had told Families SA regularly of their concerns. She said that Ashlee
could go from being reasonable to quite unreasonable very quickly. Her reading of
the assessment by Ms Stewart was that ‘yet again’ Ashlee had ‘turned on the charm’
and Families SA were going along with that. She said Louise Place staff had
regularly expressed their fears for Chloe to Families SA. Ms Lachlan believed, and
expressed this belief to Families SA, that Ashlee would only do what was necessary
to get her own way to keep Chloe.
7.10. Tellingly, Ms Lachlan made the following comment about Ashlee and her attitude to
Chloe:
‘… she saw Chloe as her possession rather than her child.’ 302
This is in accord with my impression of the situation having heard all of the evidence
in this case and having read the voluminous documentary exhibits303.
7.11. Ms Lachlan acknowledged that there were in Ashlee what she described as a ‘few
flashes of reasonable parenting’, but added that they were few and far between304.
Ms Lachlan had no hesitation in saying that by the time Ashlee was evicted from
Louise Place if she had been the Families SA worker involved she would have
removed Chloe to keep her safe305. She said that following the eviction she and
Louise Place staff held a debriefing session. They all felt that Chloe was at high risk
and they did not feel that she was safe with Ashlee306.
7.12. Ms Lachlan said that after Ashlee’s eviction her workers had to clean the unit and
remove all the rubbish from it. She said that they had to get cleaners in which is
something that does not usually occur, because of the state of the unit307. She said that
the unit, which was in very good condition immediately before Ashlee’s tenancy, was
filthy and a lot of rubbish was left behind. She said there was only one sheet left on
the bed in the unit and it was in such a condition that they threw it away without
attempting to wash it. She described the conditions as appalling308. When asked for
her view as to what might account for the disconnect between the view of the Louise
302
Transcript, page 1275
303
Refer to Section 17 of this Finding – Children are not possessions
304
Transcript, page 1276
305
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306
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307
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308
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Place staff and the view of the Families SA staff of Ashlee’s time at Louise Place, Ms
Lachlan said that she felt:
‘It was almost like they didn’t take (Ashlee’s negative behaviour) into account but they
took into account the few little things that Ashlee did almost to appease them.’ 309
Ms Lachlan said that the staff of Louise Place had never experienced the same level
of aggression with any other young woman as they experienced with Ashlee, and that
Ashlee’s anger stood out, and her offensive behaviour to staff in particular stood
out310. She said that all of the staff had hopes that Chloe would be removed from
Ashlee’s custody311. She summarised her rationale for removal of Chloe from
Ashlee’s custody as:
‘Ashlee’s absolute lack of thought for Chloe’s wellbeing.’ 312
7.13. Ms Lachlan was asked about a letter written by Ms Kartinyeri on behalf of Louise
Place stating that Ashlee’s rent had been paid so that Ashlee could use the letter for
subsequent applications for accommodation. However, at the time the letter was
written the Louise Place staff did not know that Ashlee had cancelled her
authorisation to Centrelink to make direct debits in favour of Louise Place. She said
sometimes they did not receive a report about payments for three weeks after the
relevant period. For that reason the letter was inaccurate, although they believed it to
be accurate at the time it was written313.
7.14. Finally, Ms Lachlan said that Ashlee had the distinction of being one of only two
young women ever to be evicted from Louise Place314.
7.15. Cassandra Fick
Ms Fick was the director of the Unley Child Care Centre in 2009 and 2010 when
Chloe was attending the Centre. She said that Chloe attended the Centre by virtue of
an Australian Government welfare benefit referred to as the ‘special childcare benefit’
which is for children who are at risk. She said the cost of the childcare is provided by
the government at no cost to the parent. She said Chloe’s case was the first time she
had ever applied for such a benefit. When Chloe started at Unley Child Care Centre it
309
Transcript, page 1277
310
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311
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312
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was noted that her speech development was slower than other children and she did not
have the food skills commensurate with her age in the use of spoons and forks.
Chloe’s preference was to use a bottle. Ms Fick said that at the beginning Chloe
attended for four full days per week and later it became five full days per week. She
said that when Chloe failed to attend she would contact Families SA and inform them.
She would notice sometimes that the attendance would then improve for a time before
perhaps dropping off again.
7.16. Ms Fick’s first concern in relation to Chloe was on 16 October 2009 when Ms Fick
was concerned about the state of Chloe’s nappy which was extremely full, in fact the
fullest Ms Fick had ever seen. She said the nappy was ‘pushed to its absolute
limits’315 and in her opinion might well have been worn for up to 16 hours. She
reported this to Families SA. Ms Fick also expressed concern to Ms Stewart that
Chloe would often attend with her bottle full of chocolate or other flavoured milk
rather than some more appropriate drink316.
7.17. Ms Fick said that she was consistently communicating her concerns to Families SA as
and when they arose. However, she did not recall ever getting feedback from
Families SA as to what was happening317.
7.18. On 15 October 2009 Ms Fick spoke with Ms Morris about Chloe appearing to be
stressed by changes in her environment at that time given that Chloe and Ashlee were
homeless. This manifested in Chloe’s concentration having been up and down318.
She said that at that time they were in a women’s shelter in the city but that there was
a bright prospect which was that some of the time they were living with Ms Benyk.
Ms Fick noted that Ms Benyk had a really positive relationship with Chloe and that
Chloe loved Ms Benyk319. Ms Fick said that she was very keen to keep Chloe at
childcare for as long as possible. She said that she believed that Chloe had come a
long way with her development and she and the other staff had created such a strong
bond with Chloe they felt it was in her best interests that they remained as consistent
as possible in her life, bearing in mind the instability that was occurring in Chloe’s
personal life320.
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7.19. On 17 February 2010 Ms Fick said that the Unley Child Care Centre had begun
introducing Chloe to the potty or toilet. She said that this was something that was
introduced by the Unley Child Care Centre for Chloe rather than by Ashlee as one
would normally expect of a mother. She said that at that time Chloe was with the
Centre five days per week and they had noted that she was showing an interest in
other children using a toilet or potty so they started to give her that opportunity as
well. She said that they purchased suitable clothing that could be used at the Centre
to provide for Chloe so that she could be fully toilet trained321. They provided
underwear and leggings that she could use for this purpose322.
7.20. Ms Fick was aware that Chloe was attending for respite with Ms Rann who was the
Time for Kids volunteer. Ms Fick said that Chloe had a very close relationship with
Ms Rann and was always excited to hear on a Friday that it was Ms Rann coming to
collect her, and following weekends with Ms Rann always was happy on her return on
the Monday323. Ms Fick said that the staff noted that after a weekend with Ashlee,
Chloe’s behaviour would be different. She would act out and have tantrums. By
contrast, when she came back from a weekend with Ms Rann she seemed to be more
relaxed and happier324.
7.21. When Ms Fick learnt that Strong Families Safe Babies were closing their file in
relation to Chloe in May 2010 she had ‘mixed feelings’ and explained that there were
still things that needed to be worked on regarding Ashlee and Chloe325.
7.22. By October 2010 Ms Fick noted that Chloe’s attendance at the Unley Child Care
Centre became more sporadic. By early 2011 Chloe’s attendance was becoming
much less consistent326. By 18 January 2011 Ms Fick had reported to Families SA
that Chloe had not attended childcare for some time and that Chloe had been observed
to have regressed in that she had been previously toilet trained, but was now observed
in nappies. Ms Fick made a notification to CARL in which she reported these things
and, furthermore, that Ashlee was reported to have a cleaning job and nights where
she was earning $900 per night327.
321
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7.23. Joy Rann
Ms Rann was an extremely impressive witness. As I have said she was a volunteer at
the organisation Time for Kids in 2009 and 2010 and provided respite care. She is the
national human resources manager for Bridgestone Australia and clearly a person of
insight, maturity and commonsense. I place a great deal of weight on her evidence.
She said that she met Ashlee and Chloe in June or July 2009. She thought because
they were both so young she could positively influence Ashlee as well as looking after
Chloe. She said she was not given too much information. She said that at this time
Chloe had just turned two years old. The purpose of the meeting was to check each
other out. Ms Rann said that following the meeting she was more than happy to have
Chloe in her home and that Chloe was an adorable, dear little soul328. She said that
she was hesitant about Ashlee, saying that she ‘didn’t trust her at first sight’ and did
not feel secure to have her in her house. This shrewd and insightful observation was,
as Ms Rann said, ‘certainly substantiated later on’329. The first time that Ms Rann had
Chloe in her care, Chloe and Ashlee were living with a friend of Ashlee’s called
Candice and were sharing a mattress in the lounge room. Ms Rann said:
‘I was handed Chloe and “off you go”’. There was no “come and let’s talk and let’s get
her familiar”. It was like “here she is, you just take her and off you go”. So that’s what I
did, I took her off and we went to the zoo and had a lovely time at the zoo.’ 330
Ms Rann said that she had thought that Ashlee might have spent a bit more time
checking her out331. She said that Chloe had mucus on her face, was dirty and smelt
of cigarette smoke. However, Chloe enjoyed her time at the zoo. Ms Rann became
aware that Ashlee moved into the Louise Place unit which Ms Rann thought was
excellent. However, Ashlee did not keep it particularly clean. Ms Rann said that
when she would pick Chloe up Ashlee would make a big show of affection to Chloe
which Ms Rann did not believe was genuine. She thought that Ashlee was trying to
paint a picture of a loving relationship. Ms Rann said that Chloe had her own room at
Ms Rann’s home and her own toys. She kept clothes for Chloe at her house which
she would dress her in as soon as Chloe arrived. Chloe would often arrive without
any footwear on. She said Chloe was always filthy when she arrived and reeked of
cigarette smoke. Ms Rann said that there was rarely a time when Chloe did not have a
328
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runny nose or a cough. Ms Rann said she took Chloe to the doctor herself a couple of
times.
7.24. Ms Rann said quite often if she texted Ashlee to tell her that she was returning Chloe,
Ashlee would instruct her to drop Chloe off at Ms Benyk’s house and she would have
to hand over Chloe to Ms Benyk. She said Chloe spent a lot of time with Ms Benyk
and her mother, Lesley Benyk and that Ms Benyk adored Chloe and vice versa and
they had a fabulous relationship332. Ms Rann described the various activities she
would take Chloe to. She would sometimes take her to the hairdresser and Chloe
would interact with everybody in the salon. She would take Chloe to playgrounds, the
zoo and Cleland Wildlife Park. She said that Chloe loved the animals333.
7.25. Ms Rann said that when Ashlee was at Louise Place, Ms Rann became aware that
according to the rules of Louise Place she herself was meant to report to the office
when she attended at Ashlee’s unit to collect Chloe. When she mentioned this to
Ashlee, she said that Ashlee became extremely angry and ranted and raved.
7.26. Ms Rann said that if Ashlee became angry with someone she would cut them out of
Chloe’s life. She said that she knew that if she did something that Ashlee did not like
then Ashlee would cut her off as well. She said if Ashlee became angry with
someone they would be ‘wiped’ and would no longer be involved in Chloe’s life. She
was aware that people who had previously been allowed to have access to Chloe were
no longer allowed to have access to her following these events334. Ms Rann referred
to an occasion in late December 2009 when she noted that Chloe’s nappy rash was so
bad that Ms Rann was absolutely astounded by what she saw. She said that it was an
inch and half to two inches down each leg and was raised and pimply and extremely
red335. Ms Rann said she put Chloe in a cool bath to see if that would soothe her and
got some cream for the area. She said:
‘… and she just in typical Chloe fashion went to sit down in the bath. You could see that
it was not comfortable for her and then that look came across her face as if to say “oh
well, get on with it, just do it”. She was very much, I think, used to the fact that things
hurt.’ 336
332
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This perceptive remark is very sad. However, I believe that Ms Rann in her evidence
showed a great deal of insight into the situation. I do believe that Chloe was used to
the miserable state of affairs she had to put up with while with her mother. Ms Rann
summarised it as follows:
‘No, Chloe just took it all in. I think one of the things I found with Chloe over the years
was that she understood that you were trying to help. She very much was a 40-year-old
in a two or three-year-old body.’ 337
7.27. Ms Rann reported the nappy rash incident to Time for Kids but asked them not to
report the fact to Ashlee as she was worried that Ashlee would shut her out. Ms Rann
said that in early 2010 she became aware that Ashlee obtained private rental
accommodation. Chloe was continuing at the Unley Child Care Centre and Ms Rann
would pick her up from there from time to time. Chloe loved the childcare centre and
her speech improved and her interaction with adults and children also. She became
more affectionate. Ms Rann regarded it as a 360º turnaround338. Ms Rann had asked
Ashlee about when she was going to start toilet training Chloe and Ashlee had
dismissed the idea. Ms Rann said that the Unley Child Care Centre started to work on
it and she worked together with them because Ashlee was just not interested and that
Chloe was more than ready because she was nearing three years of age339.
7.28. Ms Rann was very concerned about Chloe’s diet and noted that all Ashlee took from
the supermarket was sweets. She did not buy fruit or vegetables for Chloe to eat340.
Ms Rann described the state of the Unley house as ‘horrific’. She said when you
entered the house the carpet was so disgusting when you walked on it that your feet
squished and that the carpet had fluid of some kind in it. The room Chloe used had a
bed in it with a television and clothes everywhere, mouldy food, half smoked
cigarettes and dirty nappies341.
7.29. Ms Rann said that on more than one occasion Chloe would be distressed when
Ms Rann had to drop her at the Unley house after having had her. She said on one
occasion in particular, Chloe did not want to go home and started crying when leaving
Ms Rann’s house. She cried all the way to the Unley house and then would not leave
Ms Rann on arrival. Chloe grabbed her by the hand and screamed and screamed that
337
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she did not want Ms Rann to go. However, Ashlee was not overly concerned and
took Chloe out the back so Ms Rann could leave342. Ms Rann noted that Ashlee did
not pick her up and cuddle her or anything of that nature. Ms Rann said that she was
very concerned about the way in which Chloe was living, which was totally
inappropriate for a child. She thought that Ashlee’s behaviour was totally
inappropriate and then she became aware that Ashlee was apparently working as a
prostitute. Ms Rann was concerned because she thought that was a dangerous
environment for Chloe to be in. Ashlee would from time to time ask Ms Rann to drop
her into town for work, saying she was a cleaner at a hotel and could she drop her off
at that hotel. However, the clothing that Ashlee wore was not a cleaner’s clothing and
Ashlee would never enter the premises where she was dropped off, she would keep
walking down the street. Ms Rann noted that after she dropped Ashlee off, Ashlee
would walk along Pirie Street in the direction of premises she understood to have
topless women and offer ‘other services’343. Ms Rann said she never asked Ashlee
about this because she knew that Ashlee would cut her off if she did. She suggested
that Time for Kids might do an impromptu visit, but they said they could not. Around
this time Ashlee kept changing her phone number. Ashlee left the private rental in
Unley at about this time and Ms Rann became aware that it was left in a filthy mess
and possessions were left behind, including Chloe’s toys.
7.30. On 25 September 2010 Ms Rann notified Time for Kids of her concerns about Chloe.
Chloe was not attending childcare every day. Ms Rann was aware that Ashlee
weighed 47 kilograms (Ashlee informed her of this). Ms Rann was concerned that
Ashlee may have been using drugs apart from cannabis. At that time Ashlee was not
having Chloe herself very much at all. Ms Rann quite often picked Chloe up from
Ms Benyk’s house. Chloe did not want to be with her mother and did not want to
return to Ashlee’s house. Ms Rann commented that Ashlee very rarely had Chloe and
remarked:
‘… I think that Ashlee’s main thought was the benefits that she gained for having Chloe.
So she didn’t want to give Chloe up, she didn’t want anyone else to have her on a fulltime basis because that would impact on her lifestyle.’ 344
Ms Rann thought that the impact that Ashlee was concerned about was financial345.
342
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7.31. In early June 2011 Chloe attended one weekend for respite care with Ms Rann and
Ms Rann said she was very smelly and unkempt and her hair was beginning to matt.
Ms Rann said that her underwear appeared not to have been changed for some time.
Her hair was so matted that it was starting to get dreadlocks. Ms Rann had entered
the house that Ashlee and Chloe were in at that time which was in Royal Park.
Ms Rann saw faeces, or what appeared to be faeces, scraped up the sides of the walls
in the toilet. Ashlee had told her that she had different men coming in to her house.
Ms Rann said the toilet was almost black and that she saw sex toys in plain sight on
the Ashlee’s bed. As a result of these observations she made a report to CARL346.
Ms Rann said that she had seen the sex toys in plain sight on Ashlee’s bed and she
asked Ashlee what they were. Ashlee told her they were dildos. Ashlee was quite
open about that. Ms Rann suggested to Ashlee that she put them away as they were in
Chloe’s sight. Ashlee responded to this by laughing347.
7.32. Ms Rann noted that with Ashlee’s transience, Chloe would lose her toys and clothes
when they moved house. She said that this produced a characteristic in Chloe where
every time Ms Rann would pick Chloe up she would say things like ‘do you still have
my doll house?’ or do you still have this or that toy? Ms Rann said:
‘So she was constantly questioning to see what’s changed, because I don’t think she liked
the change very much. I don’t think that mum gave her the undivided attention that she
was seeking.’ 348
7.33. From this time Ms Rann noted that the relationship between Chloe and Ashlee
appeared to have deteriorated. She said that Chloe would push her mother away when
her mother went to hug her. Ms Rann said that she would tell her stories about her
mother which Ms Rann found hard to determine whether fact or fiction because of
Chloe’s young age. In response to the CARL notification Ms Rann did not receive
any contact from Families SA to ask for details, nor any other form of feedback349.
7.34. On another occasion in 2011 Ms Rann spoke to Ashlee and she was glassy eyed. She
said that she had been smoking cannabis and she had Chloe with her. Ms Rann said
345
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Exhibit C74, page 88 and Transcript, pages 1657-1659
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that it would be a good idea for Ashlee to go outside and not do it in Chloe’s
presence. Her response was simply to laugh350.
7.35. Ms Rann described an occasion when Chloe was playing with Ms Rann’s iPad.
Unfortunately Chloe spilt milk on the iPad and when Ms Rann approached her, Chloe
was trembling in fear. Ms Rann asked her if it was an accident and she said yes and
Ms Rann said well if it was an accident and you did not mean to do it, it does not
matter. Ms Rann was very concerned when, for the rest of the day, Chloe constantly
referred to the incident saying ‘it was an accident Joy, it was an accident, I didn’t
mean to do it’. Ms Rann said this made her wonder what happened at home that
Chloe was so petrified over something like that351.
7.36. Ms Rann said that she became aware that Ashlee met McPartland in about September
or October 2011. She met him both at the Royal Park address and then at the Ingle
Farm address after Ashlee moved in with him at that location. Chloe told Ms Rann
that McPartland was Ashlee’s new boyfriend. Ms Rann said that when she met him
he made no effort to engage. She never saw him show much interest in Chloe. She
thought the house at Ingle Farm was McPartland’s grandmother’s house, but she was
never invited into the house. Ms Rann said that it was only for a short time after
Chloe moved into the house at Ingle Farm with her mother that Ms Rann maintained
contact with Chloe. Shortly after that she thought that Ashlee had cut her off.
7.37. Ms Rann said that her last recollection of Chloe was the last time she took Chloe back
to the Ingle Farm address. Chloe was screaming and trying to get back into
Ms Rann’s car because she did not want to stay there352. Ms Rann tried to make
contact with Ashlee over the Christmas period in 2011 but her texts went unanswered.
7.38. Finally, Ms Rann was asked whether she was still involved with the Time for Kids
organisation and she replied that she was not:
‘I tried after Chloe passed away and just couldn’t do it and – nobody’s Chloe, I think that’s
the best way of finishing it, nobody’s Chloe. I’ve gained a significant health issue since
that time, so I think it’s the best outcome.’ 353
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8. Emeritus Professor Freda Briggs – the content of the social work undergraduate
degree course
8.1. Emeritus Professor Freda Briggs is at the University of South Australia and has
extensive experience in the child protection field, and that of child development.
Professor Briggs expressed concern in her evidence that social work students on
completion of their degree course had obtained little insight about children and were
unable to tell the difference between normal child development and abnormal child
development and that this would lead to mistakes being made in the child protection
area354. She also commented that social workers must be trained to relate well to
children because, if they could not, they would choose instead to relate to the adults
and listen to them, thereby missing important information. She said that there was no
course content in the social work course relating to child protection355. She has
campaigned over a long period to have changes made to the content of the social work
course. However, she said that her discussions have not been fruitful because the
course content is accredited by the Australian Association of Social Workers356.
Professor Briggs remarked that social workers are responsible for assessing the safety
of children and yet their training in child development is not as good as that of a
kindergarten teacher357. Yet kindergarten teachers are not required to make the
serious decisions that social workers make358.
8.2. Professor Briggs was concerned that inadequate training leads to social workers
relying on their emotions rather than their professional knowledge359. She was
concerned that the Australian Association of Social Workers is making a submission
to the current Royal Commission into Child Protection Systems that the employer,
namely Families SA, should be responsible for training students to work in child
protection. Professor Briggs regards that position as unrealistic360.
354
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357
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8.3. Professor Briggs was asked about cases of neglect of children and commented that
experienced social workers become accustomed to seeing houses in which neglect
takes place. She said that they can become acclimatised and:
‘…what they think is okay, a lot of other people wouldn’t. For example, teachers despair
that they have a neglected child. If the parents are drug addicts, it can be dismissed as a
lifestyle choice when the child is being neglected as a result of the drugs.’ 361
8.4. Professor Briggs regarded it as completely irresponsible to send a student social
worker to work with a potential child neglect case. She said that student social
workers do field work to learn, not to lead. She said they have to be supervised362.
8.5. There is no statutory registration system for social workers. In my opinion it is
appropriate that there should be. In his submissions the Commissioner for Victims’
Rights suggested that registration could be achieved through the National Registration
and Accreditation Scheme which resulted from the Council of Australian
Governments agreement in 2008. That may well be an appropriate mechanism for
achieving a system of registration for social workers. I intend simply to recommend
that the Minister for Child Protection Reform introduce a measure to provide for
registration of social workers. The solution suggested by the Commissioner may
commend itself to the Minister as a suitable way to implement that recommendation,
but that is a matter for the Minister. Furthermore, I intend to recommend that there be
a mandatory restriction on student social workers and qualified social workers with
less than 12 months experience having client contact without direct supervision by a
senior social worker.
9. Anthony Kemp – former Director, Practice Development Families SA – an
overview of Families SA culture and practice
9.1. Mr Kemp is presently the Deputy Secretary with Children and Youth Services in the
State of Tasmania. He qualified as a social worker in the United Kingdom in 1982
and between 2010 and 2013 was the Director, Practice Development in Families SA.
His job was to look at the roles of senior social workers and principal social workers
but the role changed over time. He left Families SA in November 2013. He did not
have any direct involvement in Chloe Valentine’s case, but he did oversee the work of
361
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the Adverse Events Review Committee and was the person to whom the adverse
events review report in relation to Chloe Valentine363 was submitted. He had to
approve the report and did so. Mr Kemp said that in 2012 there was a recognition that
there were problems within Families SA in effectively responding to child protection.
He described it as a ‘burgeoning recognition’, that the structure of child protection,
how it was delivered, who delivered it and what they were doing was fundamentally
flawed364. He said that it was quite clear that changes needed to be made and that it
would not be sufficient to tinker around the edges. He said the first step was to
acknowledge that the system was broken. He said that there was a problem with the
quality of practice amongst social workers in Families SA. He said there were
systems that were meant to support good practice but were in fact getting in its way.
He said also there was a legacy of toxicity in the agency which was not unique to
Families SA. Importantly, he said that assessments of information gathered by social
workers about cases were ‘fundamentally not assessments, they were story telling’365.
He said workers were gathering lots of information but not analysing it. He said that
there was a lack of clinical supervision and a lack of leadership right through to the
top of Families SA. He said Families SA was being seduced into mediocrity. He was
commissioned by senior management to prepare what he described as a ‘state of the
nation address’ for the situation that the organisation was in and what needed to
happen. He did so. It was entitled ‘Adopting a practice approach in Families SA’366.
9.2. Mr Kemp had some involvement subsequently in the work of Families SA to
implement some of the changes that needed to be made. However, he reached the
stage where he disagreed with the direction that Families SA was taking and felt that
he could no longer remain there. He was successful in obtaining the role in Tasmania
and left Families SA in November 2013. Mr Kemp had been provided with all of the
transcript of evidence that had been taken to the point at which he was called as a
witness. He had also had the opportunity to review the adverse events review report
that he himself had previously approved. Mr Kemp was invited to comment on the
key events in the management of Chloe’s case and how it reflected generally
problems in the culture and practice of Families SA. Mr Kemp was asked about the
approach to the case in the immediate aftermath of Ashlee being confronted with the
tape of her admitting to drug use and the subsequent allocation of the case to the
363
Exhibit C117
364
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Exhibit C117a
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Strong Families Safe Babies program. He was asked to comment on the case
conference notes of that time and remarked that he considered that the risk factors to
Chloe were ‘sanitised’ or ‘minimised’ with a view to giving Ashlee ‘a chance’367. Mr
Kemp talked about the approach that was taken from that point, namely to support
Ashlee to keep Chloe almost at all costs. He remarked that Families SA surrounds
problem parents with things that they think might make the child safe, but in this
instance he commented:
‘So asking a 16 year old to stop taking drugs … is simply nonsense in terms of being able
to understand capability. This is not a highly educated teenager who’s had a cherished
childhood who found herself pregnant. This is a chaotic young woman who has found
herself as a mother at the age of 16 years of age.’ 368
He remarked that in a situation such as Chloe and Ashlee’s, anything less than
Families SA parenting Chloe by ‘proxy’, almost from breakfast through to night time,
would not be sufficient to satisfy Families SA about Chloe’s safety369. He noted that
it was unrealistic to expect Ashlee to change her behaviours while she was parenting.
He summarised his remarks in this context by asking the question, ‘was it safe to
leave the child here with the mother while she is having her capacity built?’370. Mr
Kemp was asked about the possibility of an application to the Youth Court at that
time. He said he thought there was enough to justify an application and remarked
upon what he thought was the atrocious quality of information in affidavits to the
Youth Court. He said that he would have preferred to have tried and failed rather than
not trying at all371.
9.3. Mr Kemp’s remark in relation to Nicholas Ratsch was that he lacked analytical skills
and as a consequence he missed opportunities372. As regards the notorious incident
when Mr Ratsch prepared the safety plan containing the words ‘Ashlee and Tom
agree that when they choose to consume alcohol or drugs’, Mr Kemp remarked that
he had a profound problem with it. He questioned its viability as a way of creating
safety for a child. He suggested that this might have been an appropriate approach
with an older person, but not with a 16 year old373.
367
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9.4. Mr Kemp was asked about the apparent different standards expected of Ashlee by the
Salvation Army on the one hand in relation to her unit at Hope Valley, and Families
SA on the other. He said that Families SA had a habit of comparing one case with
another and saying how bad is this in relation to another case they have seen. This
leads to the situation where different conclusions might be reached by workers on the
one hand and providers such as the Salvation Army on the other.
9.5. Mr Kemp was asked to comment upon the situation that existed when Mr Ratsch left
the Strong Families Safe Babies team in April 2008 and Ms Kidner, the social work
student, took up the lead role. Mr Kemp said that it was completely unsatisfactory
that a student would be allocated a case even briefly. He said he held this view
notwithstanding the involvement of Ms Daniel, the family support worker374.
9.6. The next event Mr Kemp was asked about was the closure of the file by Strong
Families Safe Babies in July 2008. He noted the case summary that was prepared at
that time and remarked that it did not align with what was known about Chloe at the
time. He said that it suffered from much more than positive spin and that he did not
agree with the case closure375.
9.7. Mr Kemp was asked about the incident when Chloe was left with the 15 year old girl
at Glenelg and police became involved later that evening with the ultimate result that
Chloe was returned to Ashlee in a chauffeured vehicle in the early hours of the
following morning. Mr Kemp regarded Families SA’s handling of this situation as ‘a
catastrophic failing’376. He regarded the response as completely misguided377.
Mr Kemp said he struggled to understand what was going through Ms Heading’s
mind in this situation and remarked:
‘… we are not so atrociously resourced that the actioning of a protected intervention …
was so impossible.’ 378
Mr Kemp remarked:
‘This was a 16 month old … who was put in the back of a taxi or chauffeur and
transported to an unknown safety environment. Utterly unacceptable.’ 379
374
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Mr Kemp said it would have been unacceptable even if they had known Chloe was
going somewhere safe, but they did not even know that. He remarked that he could
not find any good decisions being made in this process at that time380.
9.8. The next incident, which as we now know followed very shortly upon Chloe being
left with that young woman, was Chloe’s admission to the Women’s and Children’s
Hospital, the absence of her mother and the discharge from the hospital to her mother
the following afternoon, all of which occurred within 48 hours of the previous
episode. Mr Kemp said that this was another opportunity where Families SA should
have intervened. He said nothing was changing, that Chloe was at serious risk of
harm. He said:
‘We discharge a child to the care of a mother who has flagrantly disregarded her role as a
parent or was simply incapable of understanding her role as a parent twice in 48 hours.
There were absolute satisfactory evidence available to us at that time that serious
consideration if not just simply going to that place of using the protective authority of the
Act for this child would have been the least that we should have done.’ 381
9.9. Mr Kemp also noted that the two intakes resulting firstly from the notification by the
police about the leaving of Chloe with the 15 year old, and the second notification that
followed the admission to the Women’s and Children’s Hospital, were rolled into one
intake. He said that that was inappropriate and should not have happened382.
9.10. It will be recalled that only a couple of weeks after these incidents a document was
prepared by Ms Curtis in which it was stated that Strong Families Safe Babies thought
that the mother had insight in relation to Chloe’s physical and emotional needs.
Mr Kemp said that he absolutely disagreed with that assessment383. Mr Kemp noted
that Ashlee’s recorded comment that she saw no issue with the events that had
occurred completely contradicted the assessment that Ashlee had insight into Chloe’s
physical and emotional needs384. He was asked about the action that was then taken to
prepare a safety plan with Ashlee. He remarked that previous safety plans had been
prepared with no effect and posed the question ‘how was a further safety plan to make
380
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any difference at this point?’. He said that Families SA’s actions were not aligned to
the impact on Chloe and remarked:
‘Writing a safety plan is – you might as well write it on the back of a postage stamp with
a tar brush, it’s meaningless …’ 385
Mr Kemp said that it was at this point that the use of the protective intervention tools
in the Children’s Protection Act 1993 should have been used386.
9.11. Mr Kemp was next asked about the notification in March 2009 when Ashlee was
punched by Lagden in Chloe’s presence and Ashlee was uncooperative with
Ms Stewart in dealing with the aftermath. He remarked that Ashlee was putting
herself in a dangerous situation and that she had ‘normalised violence’ within her
relationship. He said that there was an absence of consideration of Chloe at that point
and that the file records indicated a lack of analysis. He said he would have expected
the case record to contain a statement of the purpose of the contact with Ashlee, what
was anticipated as an outcome of the conversation, a short transcript of what took
place, then an analysis and an action plan. He said:
‘There is a saying in practice that if you don’t know where you’re going, you will end up
somewhere else, and this case has that written all over it. Nobody seemed to know
where we were going. What you have then are chronic incidents which have been taken
in blissful isolation to the whole story, and an attempt then to try and reconcile a mother
who is clearly struggling, and is clearly incapable of parenting safely, with a custom and
practice of minimising risk and in some ways, rewriting the script of risk.’ 387
9.12. Following the incident of domestic violence involving Dylan Hindle in August 2009,
Mr Kemp noted that Ashlee appeared not to acknowledge that this was having an
effect on Chloe. He said that just because the mother does not believe that it is
deleterious to the child is not a reason for us to believe the same:
‘There is no assessment as I can see from here that says ‘Thank you for your thoughts on
that mum, but these are my thoughts, and my thoughts are that you are continuously
demonstrating to the point where it is no longer safe or viable for you to continue
parenting this child’. Of course that decision should have been made a long time ago, but
here we are months and months down the road and we still have the same behaviours.’ 388
385
Transcript, page 1982
386
Transcript, page 1983
387
Transcript, page 1990
388
Transcript, page 1995
105
Mr Kemp added that the time that Ashlee was taking to appreciate these things was all
very well, but she was the mother of a child and the child’s developmental needs
could not wait389.
9.13. Mr Kemp remarked about the culture of child protection agencies that there is a sense
of ‘learned helplessness’ which is often seen in the clients of the agencies, but
sometimes also in the agency itself. He said:
‘And we learn – it’s – in the organisational literature, it’s a disabling and paralysing thing
for agencies to get to where they, themselves, almost replicate the very behaviours that
they’re working with, with families.’ 390
In this he was suggesting that the agency reaches a level of despair commensurate
with that of the service recipient and begins to search for what he described as ‘grains
of evidence’ that the situation of the family remained viable.
9.14. Mr Kemp was asked about the very negative perceptions the workers generally had
about the prospects of success in the Youth Court. He said that he was aware that
there was a perception about the complexity of applications to the Youth Court. He
said that he did not concur with that sentiment. He said he thought that it was a
simplistic answer to a complicated question and amounted to an attitude of ‘it’s too
hard; we won’t do it’ and that this was not the solution that was required. He said
Families SA needed to improve the standard of their applications to the Court391. On
the subject of family care meetings under the Children’s Protection Act 1993
Mr Kemp commented that any opportunity to use the act as a ‘leverage point for
change’ should always be considered392. He said that he found it bizarre that the
legislation was used as the last resort rather than as a safety measure for the child to
be deployed as and when needed393.
9.15. Mr Kemp was next asked to comment on the case closure summary prepared for the
closure of the case in early June 2010. He was scathing about this decision and this
document. He said:
‘I am utterly speechless. This is my first time of reading this. I cannot find one scintilla
of evidence to support the assessment, and leaving aside the case closure for a minute; I
am just saying it is simply – it is not even sugar coating, it is beyond that. It has reached
389
Transcript, page 1996
390
Transcript, page 1998
391
Transcript, page 2004
392
Transcript, page 2025
393
Transcript, page 2025
106
a point of – there is just no integrity to that assessment. I would suggest it is not even an
assessment; it is just a series of sentences that simply contradict themselves, have no
basis in reality, some of them, secure attachment … everything I have read up until this
point, which I am assuming is the same amount of information that they would have had
available to them at this time, tells me exactly the opposite. This child had no
attachment with her mother.’ 394
9.16. Mr Kemp remarked that the case closure summary contained the words that there
were no current child protection concerns. He said that may have been the case on
that day, but it was not that day that they needed to be concerned about. He said the
system is geared towards the question whether the child is unsafe on a particular day,
and if the answer is that the child is safe that day, then Families SA somehow moves
towards closing the case. He said this is completely at odds with the notion of
cumulative harm and ‘joining the dots’395. Tellingly, Mr Kemp said:
‘… a moment in time of alleged safety does not a child safe make and that’s what we’ve
got here.’ 396
9.17. Mr Kemp was asked about the subject of intakes being closed with no action because
there were no available staff to investigate. He said that he was aware of that practice
when he was in Families SA. He said that it had caused him, and he said many
others, extraordinary anxiety and distress about the fact that it happened. He said
whether it has to happen or not is a separate question397. He said that the practice is an
extraordinary practice that he had never experienced in his professional career until he
got to South Australia398. He said that it is true that there was far too much coming in
‘the front door’ for the service to manage and that there was nothing new about that in
Families SA or any other jurisdiction399, but he did not accept that it was simply a
matter of more resources. He said that is a ‘seductive’ idea, but that it was necessary
to consider whether the existing resources were being used properly. He noted that
the structure of Families SA, with a number of different metropolitan and regional
offices, was an inefficient use of resources. He described them as fiefdoms and that
every office was its own empire and did its own thing400.
394
Transcript, page 2030
395
Transcript, page 2032
396
Transcript, page 2032
397
Transcript, page 2035
398
Transcript, page 2035
399
Transcript, page 2035
400
Transcript, page 2036
107
9.18. Mr Kemp was asked about the home visit by Craig Rainsford and Anna Clarke in
January 2011 when they spoke to Ashlee but did not engage Chloe. Mr Kemp said
there should have been communication with Chloe:
‘It is just a non-negotiable that when a child is in a position to express something … they
should do that by sitting her down, getting her to draw, getting her to do something.’ 401
He said:
‘I find this whole story very, very sad, very sad that, you know, she was telling us stuff
here and we ignored her. We absolutely ignored her.’ 402
9.19. Mr Kemp was asked to comment on Craig Rainsford’s assessment following that
home visit. He was very critical:
‘What he’s doing there or what is being expressed there is what is being crudely
understood to be an assessment based on an individual moment in time. So what he’s
doing is reflecting exactly and he’s used the word, snapshot. It is on this day at this time,
is this child at risk. If that’s your frame of reference then that is factually correct, but that
is not your frame of reference if you are understanding a child’s journey through trauma
and harm.’ 403
9.20. On the question of cumulative harm Mr Kemp noted that the renotification rate is
extraordinarily high in Families SA, which is the rate at which children were notified,
the case closed and there was a subsequent renotification. He described it as children
being recycled through a system until it gets too serious and then there is only one
choice, namely to remove the child404.
9.21. Finally, Mr Kemp remarked that it was extraordinary that the option of removing
Chloe had not only been considered, but had been a critical part of Families SA’s
thinking at all times across this case405.
9.22. I was extremely impressed by Mr Kemp’s grasp of the evidence in this case and of its
implications for the culture and practice of Families SA. I accept his evidence. It was
not challenged by counsel for the Department for Education and Child Development.
Mr Kemp’s evidence as a whole should be considered and included as a part of the
redesign process that Mr Harrison gave evidence about and I propose to recommend
accordingly.
401
Transcript, pages 2045-2046
402
Transcript, page 2046
403
Transcript, page 2049
404
Transcript, page 2072
405
Transcript, page 2077
108
10. An analysis of the Children’s Protection Act 1993
10.1. The operations of Families SA are governed by and carried out under the Children’s
Protection Act 1993 (the Act). The Act is fundamental to everything Families SA
does in connection with child protection and every action, decision and thing that was
done by any of the employees of Families SA in relation to Chloe Valentine was
governed by the Act. It is important then to see all the facts that occurred so far as the
child protection workers are concerned in the context of the Act. For the purposes of
this part of the finding, I will refer to the Children’s Protection Act as in force from
1 July 2014. The relevant provisions are no different from the provisions as in force
during Chloe’s life.
10.2. I do not propose to refer to every provision in the Act in this analysis, but simply to
highlight those that, stripping the Act to its basics, form the essential structure. The
objects of the Act are set out in section 3. The first object is to ensure that all children
are safe from harm. Another object is to recognise the family as the primary means of
providing for the nurture, care and protection of children.
10.3. In section 4 the Act recites that its fundamental principles are that, firstly, every child
has a right to be safe from harm, secondly every child has a right to a safe and stable
family environment and that these two principles are the paramount considerations in
the exercise of powers under the Act. The provision also says that in determining a
child’s best interests consideration has to be given to the desirability of keeping the
child within the child’s own family and the need to preserve the family. Even where a
child is placed in alternative care efforts must be made to maintain relationships with
the child’s family. The expression family is defined in section 6 of the Act. It means
the child’s immediate family (including all guardians) and the child’s extended
family, that is to say, all other persons to whom the child is related by blood or
marriage. The expression abuse or neglect is an important expression in the act and it
is defined also. Given that all of the notifications relating to Chloe were about
neglect, I will only refer to that aspect of the definition. Essentially, the neglect of a
child means neglect to the extent that the child has suffered or is likely to suffer
physical or psychological injury detrimental to the child’s wellbeing or that the child’s
physical or psychological development is in jeopardy.
10.4. The Act sets out the general functions of the Minister and the general functions of the
Chief Executive. It is not necessary for this analysis to elaborate on those functions.
109
10.5. Part 4 of the Act deals with notifications and investigations. Division 1 deals with
notification of abuse or neglect. For the purposes of notifications, the definition of
abuse or neglect is extended to include a reasonable likelihood of a child being
neglected by a person with whom the child resides. Section 11 of the Act deals with
mandatory notification and was the provision under which the 22 notifications
relating to Chloe were made to the Child Abuse Report Line. In summary, Division 1
deals with the process by which people who are concerned about the welfare of a
child can notify their concerns to Families SA.
10.6. Division 2 of Part 4 of the Act provides for the removal of children in danger.
Essentially, it is the provision under which a police officer or an employee of Families
SA may remove a child from a situation of serious danger. This provision was never
utilised in relation to Chloe. It is in the nature of an ‘emergency’ provision. If a child
is removed under that section and is not already under the guardianship or custody of
the Minister, the child must be returned to his or her home by the end of the working
day following the day on which the child was removed. Of course, in the meantime,
an application might be made to the Court under the provisions I will come to next.
10.7. Division 3 of the Act deals with investigations. I propose to analyse this division
more closely because in each of the 22 notifications to Families SA about Chloe, and
on a number of other occasions not triggered by a notification, there were
circumstances in which an investigation into whether Chloe was a child at risk could
have been carried out. Section 19(1) of the Act says that if the Chief Executive
suspects on reasonable grounds that a child is at risk and the risk factors are not being
adequately addressed, the Chief Executive must cause an assessment of, or
investigation into, the circumstances of the child to be carried out. The section also
says that as an alternative the Chief Executive can effect a response that more
appropriately addresses the potential or actual risk to the child. However, it is plain
that if the Chief Executive is provided with an allegation that is credible and that
gives rise to a suspicion that a child is at risk, the Chief Executive is obliged to carry
out either an assessment or investigation into the child’s circumstances. In effect, it
seems to me that there is little difference between the expressions assessment and
investigation in this context. If the Chief Executive has no information about the
circumstances of the child when the notification is made, then it is only by an
investigation – and I use the word investigation here in its widest sense – that the
110
Chief Executive can progress the matter. So the obtaining of even the most basic
information in relation to a child would in this context form part of what might be
described as an investigation, and the Chief Executive is unable to progress the matter
at all without obtaining basic information by making enquiries. The making of basic
enquiries will then provide leads of other more specific enquiries that should be made.
This is a process of investigation by which any person charged with the responsibility
for establishing the circumstances of a matter must proceed.
10.8. Next, section 19 goes on to provide that under the authority of a warrant issued by a
magistrate, a police officer may enter or break into premises, seize items or require
persons to furnish information ‘for the purposes of assisting an investigation’.
Nothing is said about the Chief Executive’s own powers of investigation, nor about
the powers of investigation that are available to the Chief Executive’s employees.
However, it is very clear that the Act does not envisage that all investigations must
involve a police officer acting in the manner referred to above on the authority of a
warrant issued by a magistrate. Indeed, I suspect that this would rarely happen.
Certainly, it never happened in Chloe’s case. It follows therefore that the Act
nevertheless contemplates that the Chief Executive or an employee of Families SA is
empowered to investigate child protection matters. For example, they would be
permitted under the power of investigation to ask questions of the child’s parents or
guardians. They would be permitted to ask questions of the person making the
notification. If the notifier, or the parents or guardians refused to answer the
questions, it is true that the Chief Executive or employee could not force them to do
so. However, it is quite clear that nothing in the Act should be regarded as limiting
their ability to ask questions of these people, which may be freely answered or not
according to the willingness of the person being questioned to answer. Unlike some
other Acts dealing with the investigation of particular matters, the Act does not confer
on the Chief Executive or an employee of Families SA a general power to enter
premises and seize items and take photographs. However, in my opinion it is implicit
that an employee may enter premises if permitted by the occupant to do so, and may
ask questions which the occupant is free to answer or not as the case may be.
10.9. Division 4 of part 4 of the Act relates to investigation and assessment orders. Under
this division the Chief Executive may apply to the Youth Court of South Australia if
the Chief Executive has a reasonable suspicion that a child is at risk and that the
111
matter needs further investigation. Thus, it may be that in a case where the Chief
Executive or an employee of the Chief Executive has attempted to investigate a matter
but been unable to obtain answers to questions or gain entry to premises, or has met
some other barrier to conducting an inquiry, the Chief Executive or employee may
elevate the matter to the Youth Court. The Youth Court can then make various orders
which facilitate an investigation including orders authorising the examination of the
child and, most pertinently for present purposes, orders authorising the Chief
Executive to require a person to answer questions put by an employee of Families SA.
Thus, by this means and with the aid of the Court, an investigation can be advanced
by the obtaining of information coercively that was unavailable on a voluntary basis.
The Court may make other orders, including orders directing reports to be provided
by professionals who have previously examined the child or a parent of the child and
so on. I need not go further than simply to say that investigation and assessment
orders are the next stage in advancing an investigation if the Families SA employees
are unable to properly investigate the case by resorting to simply asking questions.
Importantly, the Court may also grant an order for custody of the child during the
investigation. Thus, in circumstances where the child might be at risk if left in the
custody of his or her parent or guardian during the progress of an investigation, the
Court can protect the child’s safety by ordering that the child be placed in the
Minister’s custody for a specified period.
10.10. The next step in the scheme of the Act is for Families SA or the Minister to apply to
the Youth Court for a care and protection order. Under this provision the Court is
empowered to grant custody of the child to an alternative carer, including the
Minister, on a more permanent basis than that envisaged under the investigation
provision referred to earlier. An order under this provision may be made until a child
attains the age of 18 years.
10.11. This part of the Act contains section 27 which provides for family care meetings. The
section says that if the Minister is of the opinion that a child is at risk the Minister
should cause a family care meeting to be convened. A family care meeting is
convened and conducted by a care and protection coordinator nominated by the
Senior Judge of the Youth Court. The purpose of the meeting is for a child’s family
in conjunction with the care and protection coordinator to make decisions as to the
best manner of securing the care and protection of the child. The care and protection
112
coordinator must ensure that sufficient information as to the grounds for believing the
child to be at risk are presented to the meeting. Section 35 of the Act provides that if
no decisions are made by a family care meeting, or if decisions are made but not
implemented or complied with, the Minister will if of the opinion that the child is at
risk and that an order of the Court for a care and protection order is required, make an
application accordingly. By section 27(2) it is clear that a family care meeting is a
necessary precursor to the making of an application for a care and protection order.
However, it is also clear that a family care meeting may be convened by the Minister
without the Minister having any present intention to apply for a care and protection
order. In other words, there is no reason why a family care meeting cannot be
convened as a means by which the Minister, and any employee of Families SA as the
Minister’s alter ego, can ‘raise the stakes’ for a parent or guardian who may perhaps
be uncooperative or reluctant to engage with Families SA’s efforts to procure a
child’s protection by educating or encouraging changed behaviour in the guardian
prior to any contemplated court action.
10.12. Mention must also be made of section 20(2) of the Act which provides that if the
Chief Executive (or any employee in the capacity of the Chief Executive’s alter ego)
suspects on reasonable grounds that a child is at risk as the result of the abuse of an
illicit drug by a parent, guardian or other person, the Chief Executive must apply for
an order from the Youth Court directing the parent, guardian or other person to
undergo a drug assessment. It will be seen immediately that this provision is
mandatory upon the Chief Executive coming into possession of evidence sufficient to
found a suspicion on reasonable grounds that a child is at risk as a result of the abuse
of an illicit drug by a parent. It is not difficult to see that the abuse of an illicit drug
by a parent will very often result in a risk to a child in that parent’s care. Certainly,
the younger the child, the more likely it is that there will be a risk and the greater the
risk will be. In the present case, there was ample evidence on a number of occasions
that Chloe was at risk as a result of the abuse of methamphetamines and cannabis by
her mother and a number of others, including the several partners her mother had over
the short time of Chloe’s life. There is no doubt in my mind that at least one, and
probably several, occasions arose over Chloe’s life when one or more employees of
Families SA must have suspected on reasonable grounds – had they turned their
minds to that question – that Chloe was at risk by reason of the abuse of one or more
of these drugs by one or more of the people referred to above. Yet on no occasion
113
was an application made under section 20(2) of the Act as required. It is no answer to
this point that none of the employees concerned ever turned their mind to the subject.
Employees are required to properly administer the Act and to be aware of its
provisions. They have a duty to keep the provisions of the Act constantly in mind in
carrying out their duties. Section 20(2) is quite clear in its terms. There is no
ambiguity and there is no discretion. The fact that it was never invoked in Chloe’s
case and that there was no adequate explanation why not, causes me to believe that
there is a systematic failure in Families SA to properly administer and apply section
20(2) of the Act. It would be interesting to know if there has ever been an application
under that section. My powers of inquiry did not enable me to determine that
question. However, the question should be considered and investigated. Section
20(2) was enacted in 2005 and came into effect in 2006. It clearly was in effect
during the whole of Chloe’s life. During the nearly eight years the section has been
on the statute books of this State one would expect, given the prevalence of drug
taking in the community and its adverse impact on the welfare of children generally,
there would have been a large number of applications under section 20(2) of the Act.
If as I suspect that is not the case, an explanation and accounting is required.
11. Adoption as an alternative placement option
11.1. Ms Carolyn Curtis was an impressive witness. She gave her evidence sincerely and
genuinely. She was obviously very much affected by the death of Chloe and by her
experience in her work with Families SA. By the time she gave her evidence she no
longer worked with Families SA having pursued a different career as the chief
executive officer of the Australian Centre for Social Innovation. She has clearly
thought a great deal about the problems faced by the child welfare system. She made
the point that the agencies ‘get to these families far too late – far, far too late’406. She
said ‘you have to get to these families earlier’407.
11.2. Ms Curtis also made the following heartfelt remark:
‘Because we can’t remove them all. If we removed them all, what would we do with
them? And there’s so many of them.’ 408
406
Transcript, page 1375
407
Transcript, page 1375
408
Transcript, page 1377
114
Later in her evidence she was talking about the difficulties in finding suitable
placements for babies and young children and she said ‘it was a struggle every time’
and that sometimes she had to resort to desperate measures:
‘I’ve put many children in hotels with nannies … sometimes caravan parks.’ 409
She went on to say that the extent of insufficiency of suitable placements is high410.
11.3. The system for alternative placement options as I understand it in South Australia is
essentially the foster care system, and in some cases, residential care. The latter is
typically provided in group homes where multiple non-related children are cared for
by paid staff on a 24 hour basis. Each home might contain up to half a dozen
children. It is notable that non-government organisations regularly advertise on
commercial radio to find people prepared to take the role of foster carers.
Disturbingly, some radio advertisements even refer to the financial benefits attached
to foster care411.
11.4. I have been impressed by the work of Dr Jeremy Sammut of the Centre for
Independent Studies in relation to the failures in Australian child protection systems
and the low reliance in Australia on adoption as a permanent placement option for
children in the child protection system412. Many of Dr Sammut’s criticisms of the
child protection system in Australia were borne out by the evidence in Chloe
Valentine’s case. Dr Sammut makes a case for early statutory intervention and
permanent removal by means of adoption by suitable families. He acknowledges that
adoption appears to be a taboo subject in the child protection world. He notes that
since the 1970s child welfare agencies have been preoccupied with family
preservation as the primary goal. He cites the report Child Protection Australia
2009-10 of the Australian Institute of Health and Welfare as follows:
‘The current emphasis in policy and practice is to keep children with their families
wherever possible. Where children, for various reasons, need to be placed in out of home
care, the practice is to attempt to reunite children with their families.’ 413
409
Transcript, page 1555
410
Transcript, page 1556
411
http://www.keyassets.com.au/south-australia/
412
Do Not Damage and Disturb: On Child Protection Failures and the Pressure on Out-of-Home Care in Australia (2011)
Sammut, Jeremy – ISBN 9781864322064 http://www.cis.org.au/images/stories/policy-monographs/pm-122.pdf and Still
Damaging and Disturbing: Australian Child Protection Data and the Need for National Adoption Targets (2014) Sammut,
Jeremy – Issue Analysis ISSN 1440 6306 – http://www.cis.org.au/images/stories/issue-analysis/ia145.pdf
413
AIHW (Australian Institute of Health and Welfare), Child Protection Australia 2009-10 (Canberra: 21 January 2011), 54–55
115
Dr Sammut remarks that families in the child protection system receive a range of
support services:
‘… every troubled parent is given virtually limitless opportunities to address their
problems.’ 414
This resonates very strongly when one considers the history of Ashlee Polkinghorne
and Chloe Valentine. Ashlee was indeed given virtually limitless opportunities to
address her problems. She was provided with at least three supported accommodation
options, she was provided with government subsidised childcare five days per week
for an extensive period, she was provided with assistance by Time for Kids and she
was provided with a great deal of support by the various workers from Families SA
who focussed on her needs, from driving her to real estate agents to find
accommodation, to driving her to Yatala Labour Prison to visit with Lagden to
advocating on her behalf with supported accommodation providers, to providing taxi
vouchers, furniture storage facilities, financial assistance to buy furniture for her
various dwellings and much more.
11.5. Dr Sammut notes that the emphasis on family preservation means that child removal
occurs only as a last resort. He refers to attempts to work with parents to address bad
parental behaviours, particularly those relating to alcohol and drugs. He makes the
following remarks which might have been written about Ashlee Polkinghorne and
Chloe Valentine:
‘Even when parents are demonstrably incapable of properly caring for their children,
child protection services fail to take appropriate action to protect vulnerable children
with well-founded and ongoing safety concerns.’
‘Too many children are being left in dangerous situations due to the misguided bias
towards keeping abusive and neglectful families together, which has swung the
pendulum too far in favour of protecting the ‘rights’ of dysfunctional biological parents
at the expense of the best interests of children.’ 415
11.6. Dr Sammut points out that the number of children in residential care throughout
Australia, and in this he is referring not to foster care but to the residential care model
I have described above, has increased by 56% in the last 15 years. By the time
children find their way into residential care facilities all other options have well and
truly been exhausted. Dr Sammut described these facilities as ‘modern day
414
Do Not Damage and Disturb: On Child Protection Failures and the Pressure on Out-of-Home Care in Australia (2011)
Sammut, Jeremy – ISBN 9781864322064 http://www.cis.org.au/images/stories/policy-monographs/pm-122.pdf, page 7
415
Ibid, page 7
116
asylums’416. Dr Sammut gives the following statistics. 61 Australian children were
adopted by non-relatives and 53 by foster carers in 2009-10 which was a total of 114
adoptions, compared to more than 8,500 adoptions in the early 1970s417. Dr Sammut
compares Australia with England where 3,200 children were adopted from out of care
in 2009-10. Of these children, 70% were aged one to four years, 25% were aged five
to nine and just 2% were under the age of one. In 70% of the cases children were
placed for adoption because of abuse or neglect. Dr Sammut calculated that if
Australian children in care were adopted at the same rate as in England, there would
have been approximately 1,700 adoptions from care in Australia in 2009-10 rather
than the quoted number of something less than 114. Dr Sammut noted that the
number of children in care per capita in the United States and Australia is very
similar. If Australian children in care were adopted at the same rate as in the United
States, there would have been approximately 4,800 adoptions from care in Australia
in 2009-10.
11.7. Dr Sammut asserts that child protection agencies have a cultural resistance to
adoption. He advocates a fundamental change:
‘Dysfunctional parents should have an opportunity to access support services to address
their problems when they first come under child protection scrutiny. But in the best
interests of children, the first chance ought be the last chance to get their acts together in
full knowledge of the looming consequences of non-compliance—the permanent
removal of children and severance of parental rights.’ 418
11.8. When one has regard to Ashlee’s abuse of illicit drugs the following extract from
Dr Sammut’s report is relevant:
‘Half to three-quarters of parents involved with child protection services are estimated as
having substance abuse problems. Given that substance abuse profoundly impairs
parenting ability, and given that substance abusers are highly prone to relapse, there are
good grounds for earlier and decisive statutory intervention to stop child maltreatment by
parents using illicit drugs and abusing alcohol.’ 419
This surely is the rationale behind the enactment of section 20(2) of the Children’s
Protection Act 1993 which, as I have noted, Families SA has culturally resisted.
416
Do Not Damage and Disturb: On Child Protection Failures and the Pressure on Out-of-Home Care in Australia (2011)
Sammut, Jeremy – ISBN 9781864322064 http://www.cis.org.au/images/stories/policy-monographs/pm-122.pdf, page 14
417
Ibid, page 16
418
Ibid, page 19
419
Ibid, page 19
117
11.9. In my opinion adoption should have a place in the alternative placement options in the
child protection system. I do not purport to be in a position to offer a settled model of
what the role of adoption in the child protection system should look like. However,
the evidence of the scarcity of alternative placement options and the notorious under
supply of suitable and willing foster parents leads me to the very firm opinion that
permanent removal to adoptive parents must have a place in the child protection
system and I propose to recommend accordingly.
12. Power of investigation
12.1. Evidence was given by Ms Leanne Stewart who at the time of giving her evidence
was an experienced social worker, well familiar with the operations of Families SA,
about the limits of a social worker’s powers of investigation. Ms Stewart was being
questioned about the occasion on 7 August 2009 when Ashlee Polkinghorne was
violently assaulted by her partner of the moment, a Mr Dylan Hindle. It was a serious
assault and Chloe was a witness to it. There is a dispute on the evidence as to when
Families SA became aware of the event. 7 August 2009 was a Friday. Regardless of
the dispute arising out of the versions on the one hand of Ms Stewart and Ms
Valentine on the other as to whether Ms Valentine contacted Ms Stewart by telephone
on the day of the assault, Families SA’s own records420 clearly show that Families SA
was made aware of the event by an employee of Time For Kids no later than the
following Monday, 10 August 2009. The documentary evidence of Families SA
recorded that an attempt was made to speak to Ashlee Polkinghorne about the matter
on 10 August 2009 but that she was evasive and unwilling to disclose the identity of
the perpetrator of the assault. The evidence from Families SA files showed that the
next step in the matter took place on the following Thursday, 13 August 2009 when
Ashlee Polkinghorne was spoken to again.
12.2. Ms Stewart was asked why she had not taken further steps to investigate the matter
between the Monday and the Thursday. For example, Ms Stewart could have
contacted any and all of the people she knew to have contact with Ashlee to see what
those persons knew of the event. Those persons included Lesley Benyk, Krystal
Benyk and Candice Owen. There were certainly other people as well, but most
relevantly, there was Ms Valentine. The Families SA records contained telephone
420
Exhibit C91
118
numbers and contact details for these people. When Ms Stewart was asked why she
did not contact any of those persons to attempt to glean further information about
what happened on 7 August 2009 she responded as follows:
‘My understanding and reasoning for not having done that on this occasion and previous
occasions, is that – I may be completely wrong and I may have been working incorrectly
for the last 9, 10 years with this, but unless there is an open investigation, we don’t have
free rein I suppose, to contact people without a parent’s consent.’ 421
She went on to say that in this context the parent was Ashlee Polkinghorne. Ms
Stewart elaborated:
‘Just to give some context; if we have an open intake, that then gives us scope under the
Children’s Protection Act to contact the notifier and any informants if we have their
details. However, in terms of general case work we need to have consent forms signed,
or at the very least, a verbal consent from someone to contact people, whether it be a
doctor who may have seen the child or a grandparent or an auntie or godparent as you
have mentioned in terms of Krystal.’ 422
12.3. Ms Stewart was asked if that was her reasoning at the time or whether she could not
remember but was suggesting it probably would have been her reasoning at the time
and she responded quite definitely that it was indeed her reasoning at the time. She
said:
‘That was my reasoning at the time and it remains an ongoing issue … in terms of
navigating the realms of confidentiality and what we are allowed to do and not allowed
to do.’ 423
12.4. I pressed Ms Stewart on this matter and suggested that it was not correct and she
responded:
‘I have never been pulled up on it; I graduated as a social worker in 2005 and all bar
about three years where I didn’t work in the department and was off having a child, I
have practised this way. I have never ever been told that that is incorrect or
inappropriate or that I should have contacted someone; I have never been directed to in a
consultation or anything.’ 424
12.5. When it was suggested to Ms Stewart that she could at least initiate an ‘intake’ by
making a notification to the Child Abuse Report Line herself, she responded that that
still would not entitle her to speak to anyone other than the notifier or notifiers as the
case may be (and in that instance, it would have been herself).
421
Transcript, page 2396 – the underlining is mine
422
Transcript, page 2396
423
Transcript, page 2396
424
Transcript, page 2397
119
12.6. When it was put to Ms Stewart that the need to obtain a parent’s consent to speak to
any person in a situation such as this with a view to obtaining information was very
limiting, she responded:
‘Yes and very frustrating.’ 425
12.7. That evidence of Ms Stewart was quite alarming. It represents to my mind not merely
a limitation on the power of a social worker to investigate an incident such as a
reported episode of domestic violence in this case, but effectively amounts to a barrier
to the conduct of any such investigation. If Ms Stewart was unable to speak to any
person without Ashlee Polkinghorne’s consent then it was impossible for her to take
the matter any further. The notes taken by Ms Stewart on 10 August 2009 do not
disclose whether she sought Ashlee Polkinghorne’s consent to question others about
the matter on that day. Very likely Ms Stewart did not bother to do so, in light of
Ashlee Polkinghorne’s refusal to cooperate by disclosing the identity of the
perpetrator or any other details and refusing to speak about the matter until the
following Thursday.
12.8. If Ms Stewart were correct in this approach to her daily work of investigating child
protection matters, it is difficult to see how any progress could be made at all, bearing
in mind that it would not be unusual that a parent who does not want to encourage the
scrutiny or interference of Families SA would be prepared to give consent to a social
worker speaking to other people. In my opinion, Ms Stewart’s view that it was
necessary for her to have Ashlee Polkinghorne’s consent before she spoke to any
other person to obtain information as to the domestic violence incident, an incident
the occurrence of which was supported by credible evidence in Ms Stewart’s
possession on that day, was plainly wrong to the extent that it purportedly relied on
the Children’s Protection Act. There was no suggestion that it relied on any policy of
Families SA outside of the Children’s Protection Act and no such policy was ever
produced at the Inquest. If there were a policy to this effect, it would be invalid
because a policy cannot limit the operation of the Act, and the Act does empower
investigation, with or without a parent or guardian’s consent. It appears to me that the
view of Ms Stewart is based on a wrong interpretation of section 19(1) of the Act
which I have referred to above.
425
Transcript, page 2399
120
12.9. It is also likely that Ms Stewart would have derived her understanding of that
interpretation of her power of investigation from conversations with others. Indeed,
in her responses on this topic she made it plain that she held this understanding of her
power of investigation following consultation with other workers and supervisors426.
12.10. Mr Tony Harrison was the Chief Executive of the Department for Education and
Child Development (previously Families SA) at the time of giving his evidence at the
Inquest, although he was not the Chief Executive during any of the period in which
Families SA was working with Ashlee Polkinghorne and Chloe. Mr Harrison was
questioned about the view expressed by Ms Stewart as to her inability to ask questions
about an episode such as the domestic violence incident on 7 August 2009 without the
permission or consent of the mother of the child. Mr Harrison effectively confirmed
that Ms Stewart’s understanding was in line with Families SA’s understanding of the
position:
‘I have picked up a practice whereby people have a view, unless there is an open case we
haven’t got the authority or the power or the justification to ask questions of people. The
only thing, if I could please add, is that under s.19(1) and (2) it very much makes
reference to the Chief Executive and then in somewhat an unusual way 19(3) in the way
that it’s been constructed jumps straight to the authorisation of a police officer and then it
talks about (3)(d) ‘require a person who may be in a position to furnish information’ – I
think which fits into the scenario you just provided – ‘relevant to the investigation to
answer questions of that’. You could interpret, I would interpret that that actually
excludes a particular prescribed person, let’s say a social worker, because it invests the
powers of a police officer to do those things, not a social worker.’ 427
12.11. In that passage Mr Harrison was referring to the powers invested in police officers
under section 19(3) to exercise coercive powers in pursuance of a warrant issued by a
magistrate (see my analysis above). As I said when discussing the effect of this
provision under the heading ‘An analysis of the Children’s Protection Act 1993’, the
powers that are vested in a police officer to act under a warrant are coercive in nature.
They give a power of entry, including forcible entry, into premises and a power to
require a person to answer questions. It is an offence for a person to refuse or fail to
comply with a requirement made of them by a police officer under the section428.
However, the coercive powers specifically conferred upon an authorised police officer
in no way inhibit the general power of investigation conferred upon the Chief
426
Transcript, page 2397
427
Transcript, page 2530
428
Section 19(6) of the Children’s Protection Act 1993
121
Executive and those employees, namely social workers, who act as the Chief
Executive’s alter ego for the purposes of administering the Act. As I said, that
general power of investigation clearly includes the power to ask questions of people
which they are free to answer or not according to their will. Nevertheless, it is very
clear that the Act does not impose any limit or prohibition on the ability of an
employee to ask questions. There is certainly nothing in the Act that requires that
consent be obtained first.
12.12. Although Mr Harrison did not say that he agreed with the view that it was necessary
to obtain consent before asking questions, his view that the power of investigation
was arguably only vested in police officers is certainly incorrect. He acknowledged
that he was of the view that there is a culture and a convention within Families SA
that has precluded staff from asking people to do things or provide information about
things429. That being Mr Harrison’s opinion after having spent some time as the Chief
Executive of Families SA, I conclude that the view expressed by Ms Stewart is
commonly held within Families SA. Mr Harrison did not offer any comment about
what he had done, if anything, to remedy the situation. Indeed, it amounts to a fair
reading of his evidence that nothing has been done in that regard. If Mr Harrison has
noted what he conceded is a culture and a convention within the organisation that has
precluded people from asking people to provide information about things, it is
alarming that he has not acted to reverse that culture. An organisation that is set up to
investigate child protection matters cannot function and carry out its basic charter
without having a culture under which it is not only appropriate, but necessary, to ask
questions if those questions will provide information that will assist in securing a
child’s safety. The fact that three years after Chloe’s death Families SA still has a
common understanding that it is not permissible to ask questions without the
permission of a parent who may or may not be cooperating with Families SA is
completely unacceptable.
12.13. I propose to make a recommendation that Families SA urgently re-educate all of its
staff to rectify the misunderstanding abroad in the organisation that questions to
secure the protection of a child cannot be asked of people without the permission of
the child’s parent or guardian. There is no such limitation, there never has been, and
429
Transcript, page 2529
122
there never should be. This message must be disseminated urgently within the
organisation. It is fundamental to the organisation’s responsibilities that its
employees have a questioning attitude and a curiosity to establish facts as to a child’s
welfare. Without this, Families SA cannot achieve its objectives.
12.14. This misunderstanding as to the powers of investigation of social workers or child
protection workers as they may as well be called, is the first of several fundamental
divergences between the practice of Families SA and the terms of the Children’s
Protection Act.
13. Divergences between the practices of Families SA and the terms of the
Children’s Protection Act 1993
13.1. The first of these divergences was the one I have already referred to, namely the
wrongheaded belief that a child protection worker must obtain the consent of a child’s
parent or guardian before being able to ask any other person any questions relating to
securing the wellbeing of that child430.
13.2. The next instance was that of section 20(2) of the Act which I referred to under the
heading ‘An analysis of the Children’s Protection Act 1993’. Section 20(2) provides
that if the Chief Executive suspects on reasonable grounds that a child is at risk as a
result of the abuse of an illicit drug by a parent or guardian, the Chief Executive must
apply for an order from the Youth Court. Mr Harrison was asked by his own counsel
if he had any comment to make about the practicality of being able to comply with
that provision in the Act431. Mr Harrison correctly noted that section 20(2) does not
provide any discretion. He correctly suggested that the section is triggered not by
evidence of abuse or neglect but by a suspicion that a child is at risk of abuse or
neglect as a result of drug use. Mr Harrison said:
‘Now, when I first identified this, I just tried to think as to how this could actually be
applied, knowing the frequency of illicit drug use in our community and that frequency
often connected with people who have children. So this needs to be explored in the
sense of if this was to occur in accordance with the legislated requirements, it would
have, my guess, a dramatic implication for resourcing and also I guess you would need
to question as to the merits of actually adopting a must-do approach to something in this
430
In expressing myself in this way I do not suggest that if an emergency presented itself in which a child’s life was clearly in
danger and the agency was satisfied that it could act urgently under section 16 of the Act to secure the child’s protection that
it would not allow this perceived restriction on its power of investigation to impede the exercise of power under that section.
However the issue was not tested in evidence.
431
Transcript, page 2517
123
particular area because, unfortunately, we do know that the prevalence of illicit drug use,
whether it’s from drugs such as cannabis, methamphetamine, heroin and others, there is a
relatively significant prevalence of the use of illicit drugs in our community.’ 432
13.3. In my opinion this is a damning piece of evidence. It was freely offered in chief. It
was not a concession made in cross-examination. As a relatively newly appointed
Chief Executive, Mr Harrison appears to have sat down and read the Children’s
Protection Act and ‘identified’ the existence of this provision and concluded that it is
impractical for the agency to comply with it. There seems to be no sense of surprise
or concern that the agency was apparently not complying with it as a matter of course.
It is implicit in what Mr Harrison said that indeed the agency was not complying with
this provision. This much became evident in the following passage:
‘Coroner Q. Are you saying – I think you’re saying – that this section at the moment is
not being complied with.
A. I would be surprised if it’s being complied with literally in the case of ‘it
must’.
Q. Well, I think it goes further than that, doesn’t it. You know it’s not being
complied with.
A. I would certainly believe it’s not being complied with, yes, that’s right,
yes.
Q. You’ve got a very strong reason to think it’s not being complied with. It’s
almost certain that it’s not being complied with.
A. Well, it’s certain in the sense as I just don’t know practically how it could
actually happen.
Q. Would you put your money on it. I’d put my money on it.
A. I would. I would put my money on it.
Q. Yes, it’s not being complied with. So let’s start with that basic fact and
your position is that if it were to be complied with, then there’d be a
massive implication for resources.
A. Yes.‘ 433
I took Mr Harrison to be suggesting two things. The first was that actual compliance
with section 20(2) of the Act would require too many resources and so is not
practicable. The second point is that there is a high level of illicit drug use, including
cannabis, methamphetamine and heroin, in our community amongst people who also
432
Transcript, pages 2517-2518
433
Transcript, page 2518
124
have children and he would therefore question the merits of approaching the court for
investigation and assessment orders in every such case.
13.4. Whatever one might have to say about resourcing, I find the second proposition of Mr
Harrison to be quite bizarre. The fact that a particular social ill relating to the welfare
of children is prevalent does not mean that society should simply accept it. Mr
Harrison came from a policing background and when he was in that role I very much
doubt that he would have ever been heard to say that the prevalence of drug taking in
the community would be a reason for police to stop actively policing the use and
possession of illicit drugs. Mr Harrison has only been the Chief Executive of DECD
since the middle of 2013, or for approximately 18 months at the time he gave his
evidence. I am left with the conclusion that in only 18 months Mr Harrison has been
so influenced by the cultural acceptance of illicit drug consumption by parents of
children in the child protection system that he is reduced to expressing an opinion that
would have been an anathema to him when he was an Assistant Commissioner of
Police.
13.5. Section 20(2) was inserted into the Act by the Children’s Protection (Miscellaneous)
Amendment Act 2005 and section 20(2) came into operation on 1 October 2006.
Thus, as at Mr Harrison’s tenure the provision has been in the Act for more than eight
years.
13.6. It is one of the most basic obligations of a Government agency to comply with the
legislation that it is required to administer. Section 20(2) is in no way ambiguous.
There is nothing difficult in its interpretation. There is no excuse for the provision to
be ignored. I note that the provision resulted from an amendment made during the
passage of the legislation through the Legislative Council at the behest of
Mr Xenophon MLC as he then was. Hansard for 1 December 2005, page 3437,
Legislative Council, records that there was a Manager’s Conference of the House of
Assembly and the Legislative Council in relation to this amendment. Mr Xenophon
said on that day:
‘It is not in the same form as the amendments I moved (both for assessment); the
government’s position in relation to treatment is the one that has, in effect, been adopted.
I do not resile from my position on the issue of assessments. I believe it is important
that, where the thresholds are crossed, both in terms of the chief executive suspecting on
reasonable grounds that a child is at risk as a result of the use or the abuse of an illicit
drug, there ought to be a drug assessment. The bill still provides for that, but there is an
125
out clause, that is, ‘unless the chief executive is satisfied that an assessment of the parent
or guardian or other person has already occurred or is to occur’. How that will be dealt
with and interpreted remains to be seen. However it is an improvement on the current
position.
The risk to children as a result of illicit drug use – in particular, amphetamines, heroin
and cannabis – is a significant issue in our community. The figures from the UN World
Drug Report show that we have the highest level of illicit drug use in the OECD, which
is a fact that ought to alarm us and ought to be the subject of urgent policy action.
So, I do not resile from my position. I understand the opposition’s view that the bill
should be passed. It did not want the bill to be withdrawn or to fail because of the
deadlock in relation to this clause. I also indicate that I understand that the minister will
be making a statement in the other place once the House of Assembly gets the message
to the effect that there will be a system of reporting (with the annual reports), so that we
will know how many cases have been brought to the attention of the chief executive in
terms of the suspicion on reasonable grounds; how many matters were assessed and the
consequences; and how those assessments proceeded and on what basis. That is certainly
an improvement on what we have now. At least the issue of drug use and its impact on
children is now on the agenda in a way that it has not been before, with some
prescriptive measures. I again endorse the comments of the Hon. Mr Lawson that this is
a case where the Legislative Council has improved legislation. I hope that in the
following year strong legislation will be introduced to tackle this very serious problem
of children being neglected and being at risk because of the drug use of their parents or
guardians.‘
13.7. My examination of the relevant Hansard does not record that the then Minister, Mr
Weatherill, made any undertaking in the House of Assembly to ensure, as Mr
Xenophon appeared to expect, that there would be a ‘system of reporting (with the
annual reports)’ about the number of cases that were dealt with under section 20(2) of
the Act.
13.8. I have not had sufficient resources for the purposes of this Inquest to investigate
whether section 20(2) has been reported upon in any of the annual reports of Families
SA between section 20(2) coming into operation and the date of the Inquest.
13.9. It is an indictment of Families SA that its practice is so completely divergent from the
clear terms of the Act. I propose to recommend that Families SA should strictly
comply with section 20(2) of the Children’s Protection Act with immediate effect.
Furthermore, that the Minister for Child Protection Reform draw the evidence of Mr
Harrison and my remarks concerning section 20(2) of the Act to the attention of the
President of the Legislative Council and the Speaker of the House of Assembly with
the request from the Coroner’s Court of South Australia that the President and the
126
Speaker draw to the attention of their respective Houses the evidence of
non-compliance with section 20(2) by Families SA.
13.10. I further propose to recommend that the Minister for Child Protection Reform
investigate whether Families SA have in any of its annual reports since 1 October
2006 reported on compliance with section 20(2) of the Act in accordance with the
understanding of the Honourable Mr Xenophon MLC as referred to above. In the
event that there has been no such reporting, that fact should also be reported to the
President and the Speaker and an explanation provided.
13.11. This aspect of the case has been particularly concerning to me. It would be useful to
reflect on what might have happened had section 20(2) been complied with in the case
of Ashlee Polkinghorne and Chloe Valentine. There was a singular instance when
Families SA became aware in the clearest possible terms that Ashlee Polkinghorne
was abusing illicit drugs. Furthermore, the agency was provided with a recording of
Ashlee Polkinghorne boasting about her drug use and boasting that it improved her
parenting of Chloe. Armed with that recording Families SA employees obtained an
admission from Ashlee that she was indeed a drug user. The admission was only
obtained after denials and hostility on her part. Had Families SA complied with its
obligations under section 20(2) on that occasion when Chloe was approximately three
months old, and made an application under section 20(2) it would have been able to
provide the Court with a record of what Ashlee had said and done and her reluctance
to admit to the drug use until she was confronted with the recording that had been
obtained. The Court could also have listened to the recording itself. It was played in
my Court during the Inquest and makes harrowing listening434. There is little doubt
that the Court would have ordered an examination and assessment of the child and an
order directing Ashlee Polkinghorne to undergo a drug assessment. It is even
conceivable that the Court might have made an order granting custody of Chloe to the
Minister for a limited period of time. Had any or all of these things occurred there is
a very real possibility that Chloe’s life might have turned out differently.
13.12. The next area of divergence between the provisions of the Act and the practices of the
agency is in the area of family care meetings. As I explained in my analysis of the
434
In my opinion, section 4 of the Listening and Surveillance Devices Act 1972 (the L&SD Act) would not be a bar to the use of
the recording in this manner, it clearly being in the public interest that the proper authorities be made aware of the risk to
Chloe disclosed by the recording (see section 7 of the L&SD Act). For the same reason I believe that the original act of
making the recording was lawful
127
provisions of the Act under the heading ‘An analysis of the Children’s Protection Act
1993’ family care meetings are a formal process governed by division 1 of part 5 of
the Act. A care and protection coordinator is responsible for convening and
conducting a family care meeting and the care and protection coordinator must be
nominated by the Senior Judge of the Youth Court435. The meeting occurs in a
relatively formal setting although nothing like as formal as a hearing in the Youth
Court might be. The meeting is intended to provide a proper opportunity for a child’s
family to make informed decisions to secure the care and protection of the child436.
13.13. To my mind, a family care meeting affords an ideal opportunity to act as a circuit
breaker when a child protection worker is encountering resistance and a lack of
cooperation from a parent or guardian of a child. It affords an opportunity for the
parent or guardian who might have become familiar with the child protection worker
and accustomed to dealing with that person, to be made accountable to another
authority, this time an authority more closely associated with the Youth Court itself.
In my view the opportunities for influencing a recalcitrant parent or guardian to
change behaviour that are offered by a family care meeting are quite clear. It offers
an opportunity to make it plain to a parent or guardian who has become accustomed to
fending off the efforts of a particular child protection worker or workers and to
avoiding their questions to be made accountable to what might be perceived as a
‘higher authority’.
13.14. It was common ground, and it is clear from the Act, that although a family care
meeting is a necessary prerequisite to the bringing of an application to the Youth
Court seeking custody or guardianship of a child that those are not the only
circumstances in which a family care meeting can be convened. Furthermore, it is
clear that a family care meeting need not necessarily be a precursor to such an
application. There is no reason why a family care meeting cannot be convened and
completed without there being a subsequent application to the Youth Court for
custody or guardianship of a child. Indeed, I note that it is only applications for
custody or guardianship that must be preceded in all circumstances by a family care
meeting. Other applications under division 2 of part 5, for example an application to
ensure that a parent or guardian undergoes appropriate treatment for drug abuse and
435
See section 29(1) of the Children’s Protection Act 1993
436
See section 28 of the Children’s Protection Act 1993
128
submits to periodic testing for drug abuse need not be preceded by a family care
meeting at all. Conversely, a family care meeting may be held without any
anticipated application under division 2 of part 5 to the Youth Court at all. Having
said that, if a family care meeting is convened and no decisions are made for securing
the care and protection of the child or if decisions are made and not implemented or
complied with, the Minister is then required to make an application to the Court if of
the opinion that a child is at risk and an order of the Court is necessary437.
13.15. The evidence at the Inquest clearly showed that Families SA does not make use of
family care meetings except for the purposes of fulfilling the formality as a precursor
to an application for custody or guardianship. For example, the evidence of Ms Curtis
was that she ‘just didn’t know what would be achieved from a family care meeting at
that point’438.
13.16. Certainly, the Senior Judge of the Youth Court is of the opinion that Families SA has
never fully embraced and utilised the mechanism of family care meetings439. The
Senior Judge referred in his letter dated 18 February 2015440 to a culture of resistance
to family care meetings in Families SA. The Senior Judge stated that the family care
meeting process is a positive benefit to everyone, including Families SA. I
respectfully agree with the view of the Senior Judge. It accords with the remarks that
I have expressed above. The Senior Judge expresses the opinion that there is a
tendency for Families SA in many cases to go through the motions of a family care
meeting as a necessary prerequisite to bringing applications for custody or
guardianship. He says that such applications are commenced at the same time the
matter is referred for a family care meeting and adds:
‘This is plainly contrary to the scheme contemplated (indeed required) by the Act.’441
His Honour continues with the following damning assessment:
‘Moreover, in cases where the Department do not want the matter to resolve at a family
care meeting they thwart the process, by refusing to fund the resolution concurred by the
family care meeting coordinator; an independent, trained and experienced officer; who
437
Section 35 of the Children’s Protection Act 1993
438
Transcript, page 1484
439
Exhibit C120
440
Exhibit C120
441
Exhibit C120
129
has persuaded the arrangements to secure the care and protection of the child. This
acknowledged policy of the Department is, in my view, quite contrary to the spirit and
intent of the Act.’ 442
13.17. This is a most alarming and damning assessment coming from the Senior Judge of the
Youth Court. Unfortunately however, it is consistent with the other instances of
divergence from the requirements of the Children’s Protection Act 1993, and the
practices and procedures of Families SA that I have already identified and referred to
above. It appears that Families SA simply does not have a proper understanding of
the legislation that governs its operations in relation to child protection. Certainly in
the case of family care meetings, Families SA does not take advantage of the
opportunities they afford and it does not utilise the provisions as contemplated by the
Parliament when it enacted the Children’s Protection Act 1993. This is very
unfortunate because it means that Families SA is not fully utilising opportunities that
are available to it to intervene more effectively in child protection cases. It is as if a
mechanic setting out to carry out servicing and repairing of motor vehicles refused to
use any other of the many tools in the workshop, including spanners, screwdrivers,
micrometers, lathes and so on and used only a hammer. The net result would be that
the mechanic would become extremely frustrated and the car would leave the
workshop in worse order than it arrived. Yes this analogy is perfectly fitting in its
application to Families SA’s blindness to the legislative tools and opportunities that
are available to it under the Children’s Protection Act 1993.
13.18. Finally I turn to the most fundamental misunderstanding of Families SA in relation to
the Children’s Protection Act 1993 and the area of greatest divergence between
practice and legislation. The overwhelming sentiment expressed by witnesses who
were employees of Families SA, with the exception of the former employee Mr Tony
Kemp, was that it is quite difficult to obtain an order for care and protection of a child
such as Chloe from the Youth Court. Indeed, it was this pervasive theme that led me
to write to the Senior Judge of the Youth Court443 to inform him that evidence had
been heard by me about the difficulties or otherwise faced by Families SA in making
successful applications for care and protection orders and asking the Senior Judge
442
Exhibit C120
443
Exhibit C120
130
whether he could provide the Coroner’s Court with statistics in respect of outcomes of
lodgements of such applications as the evidence before me that that stage was of
necessity of an anecdotal nature. The Senior Judge responded most helpfully by letter
dated 18 February 2015 with the statistics I requested. They are as follows:

13.19. The Senior Judge also provided some comments on the table set out above which
summarises the data from 2009/10 to 2013/14. He said that it can readily be seen that
Families SA has been successful in every single application for investigation and
assessment orders, extension of investigation and assessment orders and care and
protection orders. No application by Families SA has been dismissed during that
period. The Senior Judge said that it is correct that some of the successful
applications may not have been entirely successful in the sense of obtaining all orders
sought. For example, an application for a long term order may have been refused but
an order for a lesser period granted. However, the Senior Judge said this would be
only in a small proportion of successful applications. The Senior Judge also rejected
any suggestion that difficulties arise in the practice and procedure of the Court. He
pointed out that the Court allows a wide scope for the tendering of evidentiary
material. The Senior Judge was unable to recall any occasion on which an affidavit or
report was rejected. The Senior Judge said provision is made for tendering of Trial
Books containing the substance of the Minister’s case at the commencement of trials.
He pointed out that the Court is not bound by the rules of evidence and acts according
to equity, good conscience and the substantial merits of the case without regard to
technicalities and legal forms444 and that workers can appear by telephone link. It is
the Senior Judge’s view that the practices and procedures of the Court are as
accommodating to all parties, including the Minister, as they could possibly be.
444
Section 45 of the Children’s Protection Act 1993
131
13.20. Counsel for Families SA did not dispute any of that. I unhesitatingly adopt the Senior
Judge’s views as part of this finding.
13.21. This leaves me with a glaring disparity between the views of the Families SA
employees (apart from Mr Kemp) as to what is possible and feasible by way of an
application to the Youth Court, and the reality of the application by the Youth Court
of the provisions of the Children’s Protection Act 1993. Once again, there is a
divergence between the culture and practice of Families SA and the legislation and, in
this case, the application of the legislation by the Youth Court.
14. Income management
14.1. This subject shares a common theme with the topic ‘Divergences between the
practices of Families SA and the terms of the Children’s Protection Act 1993’. The
divergence in this instance is between another powerful legislative tool at the disposal
of Families SA and Families SA’s knowledge of that tool. Furthermore, to the extent
that any knowledge had penetrated Families SA on the subject of income
management, Families SA had encumbered its flexibility in the use of this most
excellent and effective tool by the imposition of an unnecessary barrier to its use.
14.2. I make it quite plain that child protection income management was not available
during Chloe Valentine’s lifetime. Its relevance in this finding is not to demonstrate
that another tool that was available at the time was not used, but rather to:
1) Note the existence of this tool from mid 2012;
2) Consider what preventative opportunities the use of this tool might have afforded
had it been available during Chloe’s lifetime;
3) Consider the use that has been made of child protection income management by
Families SA between mid 2012 when it became available and today;
4) Make appropriate recommendations.
14.3. I am referring to section 123UC of the Social Security Administration Act 1999 of the
Commonwealth. A useful summary of how child protection income management
works is to be found in the extract from Exhibit C121 shown over the page.
132
133
14.4. Mr Kai Cantwell is the Acting Director of Income Management Operations, Financial
and Social Capability Branch of the Commonwealth Department of Social Services445.
He is authorised to speak on behalf of the Department in relation to section 123UC446.
He gave evidence by video link.
14.5. Mr Cantwell referred to a Bilateral Agreement for the Implementation of Income
Management between the Commonwealth of Australia and the State of South
Australia which forms part of his statement447. The agreement was signed by the Hon
Jenny Macklin MP on behalf of the Commonwealth Government and the Hon
Jennifer Rankine MP and the Hon Antonio Piccolo MP on behalf of the South
Australian Government. The Bilateral Agreement contains the following notable
material:
1) The key objectives of income management are to:
a) reduce immediate hardship and deprivation by directing welfare
payments to the priority needs of recipients and their children;
b) reduce the amount of discretionary income available for alcohol,
gambling, tobacco and pornography;
c) encourage socially responsible behaviour, particularly in the care and
education of children;
2) Under Income Management, a proportion of an individual’s welfare payment
is prioritised for essential items such as food, clothing and housing. In cases
445
Exhibit C121
446
Section 123UC is as follows:
123UC Persons subject to the income management regime—child protection
(1) For the purposes of this Part, a person is subject to the income management regime at a particular time (the test time)
if:
(a) at the test time, the person, or the person’s partner, is an eligible recipient of a category H welfare payment; and
(b) before the test time, a child protection officer of a State or Territory gave the Secretary a written notice requiring that
the person be subject to the income management regime under this section; and
(c) the notice was given:

(ii) in the exercise of the executive power of a State or Territory; and
(d) at the test time, the notice had not been withdrawn or revoked; and
(e) at the test time, the State or Territory is a declared child protection State or Territory; and

(g) at the test time, the person is not subject to the income management regime under section 123UF.
(2) For the purposes of this Part, a person is subject to the income management regime at a particular time (the test time)
if:
(a) at the test time, the person is not subject to the income management regime under any other provision of this
Subdivision; and
(b) at the test time, the person has a Part 3B payment nominee; and
(c) at the test time, the Part 3B payment nominee is subject to the income management regime under subsection (1).
447
Exhibit C121
134
where children are at risk of neglect, it also ensures that welfare payments
are spent in the best interests of children. Income managed funds cannot be
spent on excluded items such as tobacco, alcohol (including home-brew kits
and concentrates), gambling and pornography;
3) South Australia has agreed to participate in the implementation of income
management on a trial basis, during a period which expires on 30 June
2016448;
4) Clause 5.5(b) of the Agreement says that as part of the trial, child protection
income management will be used as an additional tool449 to assist Families
SA child protection workers in meeting the needs of children, young people
and families in the trial locations. Child protection workers will be able to
give a notice to DHS450 for child protection income management. The
decision making process under which Families SA will give a notice will be
set out in Families SA policy and procedures451;
5) Clause 6.2 of the Agreement says that child protection income management
provides a tool that the State can use as part of its functions, powers and
duties in relation to the care, protection and welfare of children and young
people. Child protection income management will redirect payments
provided by the Commonwealth to promote the care and protection of
children and young people by ensuring that family income is appropriately
prioritised to meet their needs;
6) One of the principles of child protection income management is that
individuals who are subject to the functions, powers or duties of a child
protection worker and who receive relevant Commonwealth income support
payments should use those payments to ensure children and young people
are adequately housed, clothed and fed452;
7) Child protection income management is intended for cases where a child
protection worker has identified that concerns for the care, protection or
welfare of a child or young person are related wholly or in part to the use of
448
See Clause 2 of the Bilateral Agreement
449
The underlining is mine
450
The Commonwealth Agency responsible for administering the Social Security Act of the Commonwealth
451
The evidence in this case disclosed that there are no such policies and procedures within Families SA at the date of the
Inquest
452
See Clause 6.2.1(e) of the Bilateral Agreement
135
available financial resources by an individual such that the priority needs of
that individual and/or their children are being inadequately met and it is
considered that income management will assist the individual to
appropriately apply available financial resources to meet their and/or their
children’s priority needs453;
8) Clause 6.2.3 of the Agreement provides that the parties, namely South
Australia and the Commonwealth, agree that child protection income
management will be used as a tool to assist the child protection process with
the purpose of achieving the following direct outcomes for the care and
protection of children and young people:
a) a portion of the individual’s relevant welfare payments is directed so that
the priority needs of any dependant child are satisfactorily met
b) the wellbeing of the child is improved as a result of the intervention;
c) the individual’s ability to manage their income for the benefit of
themselves and their children is improved;
9) Clause 7.2.b.ii provides that it is part of the Commonwealth’s responsibility
under the agreement to ensure that persons subject to income management
are not disadvantaged and that they have access to a good range of
convenient and culturally appropriate shops, services and facilities through
the development of a merchants strategy. This will extend to people who
move outside the relevant trial location but remain on income management;
10) Clause 7.3.a.i provides that the South Australian Department for Education
and Child Development (Families SA) will identify individuals who reside
in a trial location and who are case managed by a case protection worker and
who may benefit from child protection income management;
11) Clause 7.3.a.vi says that the South Australian Department for Education and
Child Development (Families SA) will provide information and data to the
453
See Clause 6.2.2(a) of the Bilateral Agreement. I note that had child protection income management been available during
Chloe’s short life it would have been ideally suited as a ‘tool’ to assist in procuring Chloe’s welfare. The evidence in this case
showed again and again that Ashlee Polkinghorne used the funds were available at her disposal, including particularly
Commonwealth support payments, for practically any purpose other than securing Chloe’s basic needs. She was frequently
unable to provide Chloe with a house to live in, she was frequently unable to provide Chloe with adequate food and she was
frequently unable to provide Chloe with adequate clothing. All of these shortcomings in Ashlee Polkinghorne’s parenting
could have been addressed and corrected by the diversion of her Commonwealth support benefits to Chloe’s needs rather
than going directly to Ashlee so that she could use them for alcohol and drugs which she clearly did.
136
Commonwealth for evaluation reports to determine how the agreement is
working;
12) Schedule 1 to the Agreement provides that the implementation location in
South Australia is the City of Playford which is defined as the City of
Playford Local Government Area. Mr Cantwell’s evidence was that this
includes some 37 suburbs454;
13) The Agreement provides that it is the responsibility of the South Australian
Department for Education and Child Development (Families SA) to
communicate the benefits of income management to child protection
workers455;
14) It is a further responsibility of the South Australian Department for
Education and Child Development (Families SA) to develop material for
child protection workers around assessment and referral processes to ensure
they are well informed of the policy and to develop information for internal
use by staff for training and ongoing information purposes as appropriate456;
15) Clause 3c of Attachment 3 to Schedule 1 of the Agreement provides that for
the purposes of an evaluation strategy which is to be undertaken by
independent researchers from Deloitte Access Economics the following
questions are to be asked:
1. What has been the impact of income management on child
neglect/abuse?
2. What has been the impact on child physical and mental wellbeing in
those families referred to child protection income management?
3. What are the barriers and facilitating factors for child protection workers
to use income management as a casework tool?
14.6. The evidence that was presented to this Inquest demonstrates that the State of South
Australia will be unable to assist Deloitte Access Economics in the evaluation process
and that each of those three questions will not be meaningfully answered because
454
Transcript, page 2228
455
Paragraph 5 of Attachment 2 to Schedule 1 of the Bilateral Agreement. The evidence at the Inquest shows that Families SA
has failed to fulfil this responsibility.
456
Paragraph 7 of Attachment 2 to Schedule 1 of the Bilateral Agreement. This is a responsibility which the evidence at the
Inquest showed that Families SA has completely failed to comply with.
137
there will be a dearth of information available for that purpose, as will become
apparent below.
14.7. The evidence at the Inquest is quite clear that no employee witness of Families SA
apart from Mr Harrison and the former employee, Mr Kemp, had any proper
appreciation, and in some cases no appreciation, of the availability of child protection
income management. This is notwithstanding the fact that as at the date of the Inquest
the Commonwealth legislation regarding child protection income management had
been in place since mid 2012 and the Bilateral Agreement had been in place for more
than a year. The most glaring piece of evidence about the use that has been made of
this child protection measure, or tool, was that of Mr Cantwell who said that as at the
date of his evidence in February 2015 there has only been one person in South
Australia who has been nominated for income management by Families SA, and that
person for only a period of six months457. The State Government solemnly
committed, through the signatures of two Ministers, to the highly detailed and
elaborate Bilateral Agreement which I have summarised above. The Agreement itself
is 84 pages long. It would seem to me that the work involved in preparing the
agreement exceeds, by a very long measure, the work that has been put into its
implementation by Families SA to date. The question that one is led to ask is: what is
the point of signing an elaborate agreement about child protection income
management and barely using it? The evidence was clear that there was a dearth of
knowledge and awareness in Families SA of the availability of child protection
income management. The witnesses were each asked about their awareness of child
protection income management and each of them had either never heard of it or had
some hazy knowledge of what is known as the Northern Territory Intervention which
does not have any relevance to South Australia.
14.8. It is clear that no proper effort has been made by the State of South Australia to
comply with its obligations under the Bilateral Agreement. This is a further example,
and a very glaring example, of Families SA failing to use a legislative tool for child
protection purposes, a tool that is readily available and easy of implementation.
Nothing more is required than for a child protection worker to enter a secure website
that is available via the Commonwealth agency and at the press of a button the task is
complete. The fact that this has only occurred once in a period of, at the very least,
457
Transcript, page 2236
138
18 months, is staggering. It is obvious that vastly more than one single person in the
Playford area would have been appropriate for the income management trial during
that period. It is obviously the case that with the trial scheduled to come to an end in
June 2016 that on the present trajectory, the State will have made no proper effort to
trial child protection income management in accordance with the Bilateral
Agreement. The extremely elaborate and thorough evaluation process envisaged by
the Agreement via Deloitte Access Economics will be a useless exercise because there
will be no data on which to form a proper evaluation.
14.9. Thus, the first major obstacle to the use of income management as a child protection
tool is that Families SA appears to have largely ignored it and has failed to inform its
staff about the availability of income management as a child protection tool, despite
the State’s obligations under the Bilateral Agreement. However, there is a second,
more fundamental, difficulty. That is that according to the evidence of Mr Cantwell
Families SA requires that a welfare recipient’s consent be obtained before they will be
referred to income management458. As Mr Cantwell said, the obtaining of consent is
not a Commonwealth requirement. Mr Cantwell appeared to be of the impression –
he was by no means certain about this – that the obtaining of consent may be a
legislative requirement in South Australia. In fact, that proves not to be the case as
confirmed to me by counsel for Families SA on instructions. Counsel informed me
that this is a ‘policy decision’ and not a requirement of any South Australian Act or
law459. It is concerning that despite being a Commonwealth official, Mr Cantwell is
more familiar with the operation of child protection income management in South
Australia than any other witness including the Chief Executive, Mr Harrison.
14.10. According to Mr Cantwell the State of Western Australia and the Northern Territory
do not require consent before the imposition of child protection income management.
He said that in Western Australia there are 301 cases of child protection income
management and there are 67 in the Northern Territory460. Mr Cantwell said that there
are three cases of child protection income management in Queensland and two in
New South Wales. His evidence was that the low numbers in Queensland and New
South Wales may also be accounted for by the requirement of consent in those
jurisdictions.
458
Transcript, page 2229
459
Transcript, page 2253
460
Transcript, page 2237
139
14.11. It seems to me to be an unnecessary burden on the effectiveness of income
management to require a person’s consent. It is quite clear from the evidence that I
heard in this case that Ashlee Polkinghorne would never have consented to income
management, and yet it is obvious that it would have been highly effective in
diverting her income to Chloe’s welfare rather than to drugs for Ashlee’s personal
use. In short, the imposition of a requirement that consent be obtained before this tool
is used effectively renders it impotent in this State. This is clearly demonstrated by
the statistics I have referred to above.
14.12. Mr Cantwell also gave very helpful evidence about the mechanics of income
management arrangements. For example, if a person living in the Playford area
becomes subject to child protection income management, they cannot escape its
consequences merely by moving out of the Playford area. Once they are subject to
income management they remain subject to income management. Mr Cantwell said
that there are a large number of merchants who accept the ‘basics card’ that is
provided by Centrelink for income management purposes. He also said that
Centrelink replaces basics cards that are lost free of charge and immediately upon the
person presenting to a Centrelink office. Thus in that respect the cards are more
convenient than bank issued credit cards. Mr Cantwell also said that it would be
possible for a child protection worker in South Australia through a conversation with
his or her counterpart in Mr Cantwell’s Department to negotiate the application of
child protection income management upon a person who was not resident in the
Playford area if the child protection worker wished to do so.
14.13. In short, there are no impediments to the wide application of child protection income
management in this State. The Bilateral Agreement itself envisages that other areas
apart from the Playford area could be included by negotiation, and as I have already
said, Mr Cantwell left open that possibility on a case by case basis. The system is
well thought out and an excellent Commonwealth Government initiative. It falls
down when it comes to Families SA actually making use of it.
14.14. This Inquest began in August 2014. The matter of income management was raised
with various Families SA witnesses from that time. Mr Harrison was the last witness
to give evidence at the Inquest in February 2015 after 30 days of sitting. I would have
expected Mr Harrison to be well aware that income management was a matter that the
Court was exploring. He was asked about the matter of consent and whether there is a
140
written policy in Families SA about the requirement for consent to be obtained before
income management is applied. Mr Harrison responded:
‘I would have to find that out for you. I’m not aware of that, whether it is the case or
not.’ 461
Mr Harrison did agree that child protection income management is an excellent tool462
and he agreed that the obtaining of consent is an unnecessary blockage to the use of
that tool463.
14.15. It has been said of measures such as income management that they rob welfare
recipients of dignity and autonomy. I note that the Commonwealth Government
announced on 22 March 2015 that it proposes to trial the use of an extended form of
income management at the end of 2015 to reduce the extent to which benefits are
spent on alcohol, drugs and gambling464. This proposed trial is not conditioned on the
existence of a child protection concern, but will apply generally. It is not for me to
comment on that proposal, but I am strongly of the opinion that money provided by
the Government as a welfare measure should not be spent on illicit drugs, alcohol,
cigarettes or gambling when a child of the recipient is subjected to anything less than
parenting that conforms to standards commonly accepted by right thinking members
of society. And when that parenting has descended to a level that has attracted the
attention of Families SA, the case is irrefutable: no welfare benefits should be wasted
on illicit drugs, alcohol, cigarettes or gambling. Finally, if it is suggested that to
impose such a measure on a parent who is believed to be abstaining from all of those
habits is patronising or condescending, I respond that if they are abstaining from those
things, they will not be adversely affected.
14.16. I propose to recommend that Families SA direct its staff to actively apply child
protection income management in the Playford area of South Australia and that the
‘policy’ of obtaining a benefit recipient’s consent to that course be abolished.
Furthermore, I propose to recommend that the State Government take immediate steps
to negotiate with the Commonwealth Government for the declaring of areas other than
the City of Playford as declared areas for the imposition of child protection income
management. There is no sensible rationale for confining to one geographical area a
461
Transcript, page 2531
462
Transcript, page 2532
463
Transcript, page 2532
464
https://alantudge.dpmc.gov.au/media/2015-03-22/doorstop-4-treasury-place-melbourne
141
tool which could have the effect of benefitting many children at risk of neglect and
abuse in this State who happen to live outside of the geographical area of the City of
Playford. It is absurd to impose a geographical limitation of that kind in my opinion.
Finally, I propose to recommend that the State Government begin negotiations with
the Commonwealth Government with a view to making the child protection income
management regime a permanent structure and to that end, negotiate an indefinite
extension beyond 30 June 2015 which is when the present Bilateral Agreement
expires.
15. Family reunification
15.1. Under the heading ‘An analysis of the Children’s Protection Act 1993’ I mentioned
that one of the objectives of the Act is to recognise the family as the primary means
for providing for the nurture, care and protection of children. I also pointed out that
the definition of family in section 6 of the Act includes the child’s extended family.
In Chloe’s case of course her extended family included her maternal grandmother, Ms
Valentine, who made it quite plain in her evidence that at all times she was willing
and prepared to take Chloe into her care465. What she was not prepared to do, was to
have Ashlee in her home because of Ashlee’s disruptive and antisocial behaviour and
the impact that that would have on Ms Valentine herself and her other family
members including her children466. Alan Polkinghorne made the same offer.
15.2. Clearly no consideration was ever given by Families SA to the option of placing
Chloe with Belinda Valentine or Alan Polkinghorne. It appeared to me that there was
an assumption that Chloe should remain with her mother and the threshold for
removal would not be reached until Chloe was actually in imminent danger of being
harmed. But Chloe suffered neglect for her whole life until the final period of
physical abuse that she was subjected to in the days preceding her death. Over that
four and a half years of neglect, in each instance where Chloe was exposed to the risk
of harm, her mother made some arrangement to lower the risk to its habitual cause of
barely adequate parenting467. So the Families SA threshold of imminent danger of
being harmed was never reached. A number of Families SA witnesses referred to the
objective of maintaining a family environment for Chloe468. However, given that they
465
Transcript, pages 2310, 2316, 2335, 2336, 2344, 2349, 2376
466
Transcript, pages 2347, 2349
467
Which I have described as unacceptable and inadequate according to the standards of rightful thinking members of society
468
Cheverton Transcript, pages 345-346, Morris Transcript, page 1176, Curtis Transcript, page 1373 and Harrison, Transcript,
page 2496
142
never gave any consideration to placing Chloe in Belinda Valentine’s or Alan
Polkinghorne’s care, even temporarily, it would seem that the conception of ‘family’
for Families SA workers in Chloe’s case was Chloe and Ashlee Polkinghorne. Ashlee
was only a couple of weeks past her 16th birthday when Chloe was born. Even the
most highly functioning, emotionally mature and responsible 16 year old is not
equipped to undertake the responsibility of caring for an infant without extensive,
constant and continuous assistance. By her actions, Ashlee had made it impossible
for her to have that kind of assistance from her mother or her father. The fact was that
there was no such assistance available for Ashlee from the moment of Chloe’s birth.
Furthermore, Ashlee was far from the model teenager I have described above. She
was emotionally immature and completely irresponsible. In short, the notion of her
being able to provide a proper nurturing family environment for Chloe was fanciful
from the outset.
16. Cumulative harm
16.1. During the course of the Inquest it was common ground that for most of her life Chloe
suffered chronic neglect. The threshold for removal of imminent danger of harm was
reached several times, but Ashlee made some arrangement to alleviate the risk, or by
the time Families SA became aware of the episode, the risk was no longer imminent.
The situation had returned to the usual chronic neglect.
16.2. Families SA approached each of these instances without reference to those that
preceded them, and the general pattern of chronic neglect over a period of years. It
was suggested that the Children’s Protection Act 1993 should be amended to make it
clear that cumulative harm is a relevant factor in making decisions about the care of a
child. I agree that this is a sensible proposal, but with this qualification: the inclusion
of the words cumulative harm in the objects section of the Act will not achieve
anything unless it is acted on. The fact is that there is nothing to prevent Families SA
building a case for a care and protection order based on sufficient evidence of
multiple instances of neglect. Merely including these words in the Act without more
will not solve anything apart from creating an impression that something is being
done in response to Chloe’s tragic death. Far more than this is needed to prevent a
repetition. Nothing less than a massive overhaul of Families SA and the culture and
training of its staff will suffice.
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17. Children are not possessions
17.1. The danger in the heavy emphasis placed on family reunification by the Children’s
Protection Act 1993 is that some people, and I include Ashlee Polkinghorne in this,
regard children as possessions or items of property. It is a terrible thing to say, but the
conclusion I have reached is that Chloe was nothing more than an item of property to
be utilised by Ashlee Polkinghorne for her own benefit. Chloe represented nothing
more to Ashlee than a means by which her income could be enhanced by obtaining
support payments not available to a childless person. She also used Chloe as a pawn
or bargaining chip to deploy in order to manipulate other people such as Belinda
Valentine, Krystal Benyk, Lesley Benyk and indeed the various child protection
workers employed by Families SA involved in the case. Ashlee simply had to
threaten these people with the prospect of denying them access to, or contact with,
Chloe unless they complied with Ashlee’s demands and requirements. The threat was
that if they failed to do so they would cease to be able to satisfy themselves that Chloe
was safe. That was the desire of everyone connected with Chloe with the exception of
Ashlee and her various domestic partners. The threat of losing contact with Chloe
and providing her with whatever succour was able to be given in the time allotted to
them for that purpose by Ashlee, was the device by which Ashlee was able to bend
them to her will.
17.2. In short, Ashlee deployed Chloe as a possession or a piece of property. She could
deploy Chloe in a way that would assist her to obtain her own personal objectives. Of
course, the various people who were manipulated by her by this device saw Chloe as a
precious vulnerable child and they all acted accordingly.
17.3. To me, the flaw in the conception of Ashlee and Chloe as a family within the context
of the Children’s Protection Act 1993, and the philosophy of Families SA, is that it
enabled Ashlee Polkinghorne to deploy Chloe as a possession.
17.4. In the course of hearing other child protection cases it is clear to me that Ashlee
Polkinghorne is not the only person in society who has this attitude to children. There
is a clear need to act early to save children such as Chloe by removing them to a safe
environment and preventing the cumulative harm that accrues while they remain in
the custody of parents who are not interested in treating them as precious children, but
simply as possessions to be applied for the parents’ advantage.
144
18. Continuity of care
18.1. Over the time that Families SA was involved with Chloe and Ashlee, many different
workers dealt with the matter for various periods. Each of them gained knowledge
about the factors that were affecting Chloe’s safety. They also gained knowledge
about Ashlee’s patterns of behaviour. There are clear and obvious benefits in using
this kind of knowledge seamlessly in the management of a child protection case. Yet
Families SA did not allocate Chloe’s file to the same worker or workers in order to
maintain continuity of care. Nor did Families SA mandate that there be a formal
handover of the case when there was a transfer of case management from one worker
to another. This lack of continuity meant that the significance of particular events and
patterns of behaviour was not recognised at crucial stages of the case. To exacerbate
the problem, note taking was grossly inadequate for much of the time. I intend to
recommend that Families SA should allocate cases to workers so that there is
continuity of care in the management of children at risk.
19. Note taking
19.1. I have found that the note taking in Chloe’s case was, more often than not, grossly
inadequate. To make matters worse there were cases of selective noting, with the
effect that the overall impression was misleading. The worst instance of this was
Ms Heading’s note on the occasion when Chloe was left with the teenager and
Belinda Valentine was asked in the middle of the night to go to an unfamiliar address
to pick her up. The note stated the Ms Valentine would do so ‘if she must’. There
was no mention of the other factors at play for Ms Valentine – her two young boys in
bed without anyone to look after them if she left, the fact that she had only one child
seat in the car, and so on. This selectivity was mischievous and deliberately
suggested that Ms Valentine was unhelpful and uncaring of her grandchild’s welfare.
The next social worker to read the file would gain an unfair impression of
Ms Valentine, with the result that she might be regarded as an unsuitable potential
placement option for Chloe. This was not only unfair to Ms Valentine, but also did a
disservice to Chloe.
19.2. Note taking is intended to record matters factually and accurately. There is, I
suppose, a place for social workers to record their opinions of people and their
behaviours and motivations in the case notes, but these should be expressly recorded
145
as opinions, and not mixed in with the factual record of the event. I intend to
recommend that Families SA train social workers in the art of proper note taking, with
emphasis on the need to be factually accurate, and make a clear distinction between
the facts of an event and the worker’s opinions and judgements about the event and
particular individuals.
20. Ashlee Polkinghorne’s responsibility
20.1. This Inquest has found many flaws in the processes of Families SA. But I have kept
steadily in mind throughout that the person with primary responsibility for Chloe’s
sad and tragic life was Ashlee Polkinghorne. I have also given a great deal of thought
to the fact that Ms Polkinghorne will be released from prison in a very few years, and
that the tragedy of Chloe’s life will be repeated in the likely event that Ms
Polkinghorne has another child, bearing in mind that she is only in her early 20s. I do
not suggest that her next child will inevitably die as a result of her criminal neglect as
Chloe did, but I am satisfied on the evidence I have seen that Ashlee Polkinghorne is
not fit to be a parent. In my opinion it would be reasonable for the Children’s
Protection Act 1993 to be amended to deal with this situation by providing that a child
born to a person who has a conviction in respect of a child previously born to them for
manslaughter by criminal neglect, manslaughter or murder469 will, by force of the Act,
be placed from birth under the custody of the Minister. The Act should then continue
to apply to the child in the same way as if the custody had been ordered by the court
under section 38(1)(d), so that the parent might apply to the court for a variation or
revocation of the custody of the Minister. Furthermore, the Minister would have the
same powers in relation to the child as any other child under the Minister’s care and
protection: for example, the Minister might, by section 51(1)(a), permit the child to
remain in the care of some other member of the child’s family. This might, for
example, include the other parent of the child, who may have no previous conviction
in relation to children, and may be a suitable person to care for the child. In such a
case the Minister should be empowered to impose conditions on the convicted
parent’s dealings with the child, if the parents are still in a relationship. That would
alleviate the risk that the proposal might work an injustice upon a person with no
relevant conviction who happens to have a child with a person to whom the section
applies. The Minister would be able to place the child with that parent, if satisfied
469
I have only mentioned murder. The amendment should also include other forms of homicide not involving a conviction, for
example, cases dealt with under section 269 of the Criminal Law Consolidation Act.
146
that he or she was committed to ensuring that the child would be protected from
neglect or abuse at the hands of the convicted parent.
20.2. The power vested in the court to vary or revoke the Minister’s custody might be
exercised in the convicted parent’s favour in the event that they could establish to the
court’s satisfaction that they had changed their behaviours and attitudes so that the
court could be satisfied that they would not subject the child to abuse or neglect. The
court might direct that assessments and investigations be carried out by appropriate
experts to assist it. By this means the proposal would not prevent a person such as
Ashlee Polkinghorne being able to demonstrate that they had, with time,
fundamentally changed.
20.3. An amendment to the Act in those terms would prevent Ashlee Polkinghorne
neglecting and abusing a future child, if it were enacted before her current
incarceration ends by remission or parole.
21. Summary of key issues
21.1. Intelligent application of the legislative tools available to secure compliance with
Families SA’s goal of forcing Ashlee to be a reasonable parent should have been the
true objective. After all, that was the only option available to Families SA if it did not
move to remove Chloe. It could either allow the matter to drift aimlessly, or it could
use whatever tools it had available to it to force Ashlee to do what was necessary.
Unfortunately, Families SA took the path of least resistance and the whole history of
its dealing with Ashlee is a history of drift, irresolution and aimlessness. Had
Families SA intelligently and strategically applied the legislative tools available to it
much more readily, and much earlier, there is every chance that one of two things
would have happened. The first possibility is that Ashlee might have changed her
ways and become a more responsible parent. As unlikely as that now seems, it must
have been a possibility given her very young age and the extended family assistance
that would have been available to her if she modified her behaviour. The other
possibility is that by increasing the pressure on Ashlee through the strategic and
intelligent application of the legislative options, the agency would have brought the
matter to a head in the short to medium term. By this I mean that if a family care
meeting had been convened and its stipulations and goals had not been met by Ashlee,
the next stage would have been to elevate the matter for strategic orders from the
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Youth Court, for example drug assessments, vocational training and so on. If those
goals had not been met by Ashlee, then the Youth Court could have been persuaded
without much difficulty to have removed Chloe from Ashlee’s care for a short or
longer term period.
21.2. Section 20(2) of the Children’s Protection Act 1993 says that if Families SA suspects
on reasonable grounds that a child is at risk as the result of the abuse of an illicit drug
by a parent, it must apply to the Youth Court to direct a drug assessment. There were
several occasions when there was ample evidence of methamphetamine abuse by
Ashlee and, multiple instances where there were grounds to suspect it. Yet no
application was ever made. The evidence of Mr Harrison showed this to be a
systematic failing in Families SA.
21.3. Mr Kemp summarised Families SA’s shortcomings. He said it was being seduced
into mediocrity. Some social workers had poor quality of practice. Their assessments
were not assessments, but story-telling. There was a lack of analysis, a lack of
clinical supervision and a lack of leadership. In summary, it was broken and
fundamentally flawed.
21.4. Ashlee was given virtually limitless opportunities to address her problems. She was
given three supported accommodation options, she was provided with government
subsidised childcare five days per week for an extensive period, she was provided
with assistance by Time for Kids and she was provided with a great deal of support by
the various workers from Families SA who focussed on her needs, from driving her to
real estate agents to find accommodation, to driving her to Yatala Labour Prison to
visit with Lagden to advocating on her behalf with supported accommodation
providers, to providing taxi vouchers, furniture storage facilities, financial assistance
to buy furniture for her various dwellings and much more. The fact is that she was
demonstrably unable to properly care for Chloe. The pendulum has swung too far in
protecting the ‘rights’ of dysfunctional parents. Instead of Families SA workers
performing menial cleaning tasks for Ashlee, their time should be used rigorously
analysing the evidence and, if necessary, building a case to put to the Youth Court.
21.5. Social workers cannot act in the best interests of a child and the child’s irresponsible
parent simultaneously. At times it seemed Chloe’s interests had been forgotten
completely while the focus was on Ashlee and her demands. A child’s interests can
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and do sometimes conflict with the parents’. It must be a standard approach for
workers to always act in the child’s best interest only.
21.6. Mr Harrison and Mr Kemp both thought that the answer to Families SA’s problems is
not necessarily more resources, yet a number of staff witnesses made that claim.
Clearly Families SA needs a system to measure the performance of individuals in its
agency and to measure work volume and uncompleted work. This Court often hears
public sector workers claiming that overwork was their reason for not doing
something which has ultimately contributed, directly or indirectly, to a death. Such
claims are easily made but should be approached with caution in the absence of
independent evidence about the volume of work actually performed by the person
making the claim and his or her effectiveness in performing that work. For example,
driving Ashlee to an appointment with a real estate agency is hardly as high a priority
as making proper case notes or contacting all informants for a particular notification.
21.7. The audio recording of Ashlee boasting about using methamphetamines and it making
her a better mother was described by Ms Francou as a turning point in the case for her
to be able to do something. Ashlee had lied to Ms Francou about drug use and even
tried to deny that the recording was her voice. Yet Ms Francou saw her as a terrified
kid of 16 being confronted by senior social workers who she would find very
intimidating. She was quite wrong. Ashlee’s behaviour was not that of a terrified kid.
It was the behaviour of an accomplished liar practised in deceit and manipulation. Ms
Francou misread her completely and was fooled into thinking Ashlee had seen the
error of her ways and would make positive changes. Ms Francou turned down
Ashlee’s offer to submit voluntarily to regular drug testing as unnecessary. That was
a fundamental mistake. Ashlee would go on with her hedonistic selfish lifestyle and
continue to neglect Chloe.
21.8. The safety agreement prepared by Mr Ratsch that used the words ‘Ashlee and Tom
agree that when they choose to consume alcohol or drugs’ directly contradicted the
undertaking Ashlee had made shortly prior to cease drug use altogether. It was
another fundamental mistake. It might have been appropriate for adult parents who
had a long history of drug use, but not for a 16 year old.
21.9. What if Families SA had complied with section 20(2) of the Act when it had the audio
recording of Ashlee boasting about using methamphetamines and it making her a
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better parent of Chloe? Families SA would have provided the Youth Court with the
audio recording and the fact that she had denied drug use up until it was played and
had even attempted to deny it was a recording of her speaking. There is little doubt
that the Court would have ordered that Ashlee undergo a drug assessment and that
Chloe be assessed. The Court might have ordered that Chloe be placed in the
Minister’s custody for a time. If these things had happened, Chloe’s life might have
turned out differently.
21.10. When the Salvation Army workers attended Ashlee’s unit and, finding it unlocked,
went inside to find the conditions to be filthy and chaotic, Mr Ratsch noted on his file
that they had trespassed. He told Ashlee that they had no right to enter her unit,
despite the fact that their visit disclosed legitimate child protection concerns. This
only made Ashlee more contemptuous of authority than she already was. It was a
foolish and ultimately dangerous thing to do.
21.11. There were at least two options of alternative care for Chloe that met the Children’s
Protection Act 1993 definition of family: Belinda Valentine and Alan Polkinghorne.
Yet neither option was ever considered. The principle of maintaining Chloe in her
‘family’ situation was applied much too rigidly.
21.12. When Chloe needed to be rescued in the middle of the night after her paralytic mother
left her in the care of a 15 year old, Ms Heading of the Crisis Care Unit decided that
Chloe would be transported by a hire car company with an unknown driver and
delivered to Ashlee who was rudely and angrily demanding Chloe’s return. Ms
Heading had first attempted to get Belinda Valentine to collect Chloe but she was
unable to do so as it was the middle of the night and she was already caring for her
own young children. Ms Heading made a note suggesting that Ms Valentine was
simply unwilling to take her granddaughter without referring to her understandable
logistical difficulties. She sent Chloe as a hostage to fate with a complete stranger
into a situation she admitted she would not have entered except in the company of a
colleague for safety reasons. She failed to discharge her duties to an appropriate
standard of care.
21.13. Ms Stewart said that when Ashlee refused to disclose to her the identity of the person
who assaulted her in Chloe’s presence and refused to further discuss the matter, Ms
Stewart believed she could not seek further information from other potential sources
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without Ashlee’s consent. If that were true, it meant that Ms Stewart could not
contact various people in Ashlee’s life to seek answers, even though she had spoken
to them previously and knew they were willing to pass on information they had. An
inability even to ask questions without the subject’s consent would be a barrier to
investigation. It was plainly wrong. Yet it was a view that was generally held in
Families SA. The Children’s Protection Act 1993 does not impose any limit on the
ability of a social worker to ask questions, and there is certainly nothing in the Act
that requires consent be obtained first.
21.14. An organisation that is setup to investigate child protection matters cannot function
and carry out its basic charter without having a culture under which it is not only
appropriate, but necessary, to ask questions if those questions will provide
information that will assist is securing a child’s safety.
21.15. When Ashlee was assaulted by Dylan Hindle but refused to tell Ms Stewart who had
done it, as a public officer Ms Stewart had been informed of a crime. In my opinion it
was her duty to report this matter to the police regardless of Ashlee’s attitude to the
matter. That was Ms Stewart’s duty as a public officer and the duty of any other
Families SA worker who became involved in the situation. In my opinion that should
have occurred at the very least.
21.16. When Ms Stewart learnt about Dylan Hindle’s paedophile history from an internet
news site but did not inform Ashlee for privacy reasons, her position was simply
preposterous. On no view could any sensible person arrive at the conclusion that
information they had obtained in the public domain could not be conveyed in these
circumstances, particularly where Ashlee needed to know about the history of the man
she was involved with. It is frightening and concerning to think that Ms Stewart
could reach such a bizarre conclusion, particularly after conferring with a colleague
who apparently agreed with her. It is difficult to comprehend how an organisation
could produce two employees who would reach a conclusion such as this. It is only
possible to conclude that there are serious deficiencies in the training of Ms Stewart,
Mr Carr and any other person who would operate in this way.
21.17. In January 2011 a notification about Chloe’s neglect and Ashlee’s prostitution was
investigated by workers Mr Bailey, Ms Clarke and Mr Rainsford. When they visited
the home they did not engage with Chloe at all although she was then 3½ years of
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age. They did not contact all the informants. To describe this as an investigation is to
glorify it with a title it does not deserve. The resulting ‘assessment’ was not worthy
of the name. It was full of inaccuracies.
21.18. Some people, including Ashlee Polkinghorne, regard children as possessions. Chloe
represented nothing more to Ashlee than a means by which her income could be
enhanced by obtaining support payments not available to a childless person. She also
used Chloe as a bargaining chip to manipulate her friends and Families SA workers.
The concept of family preservation should only apply to parents who treat their child
as precious – not a mere possession to be used for their own benefit.
21.19. The inclusion of ‘cumulative harm’ as a criteria of risk in the Act is an
unobjectionable proposal: but merely including the words in the Act without more
will not solve anything apart from creating an impression that something is being
done in response to Chloe’s tragic death. Far more than this is needed to prevent a
repetition. Nothing less than a massive overhaul of Families SA and the culture and
training of its staff will suffice. The question should not be whether a child is safe at
a given point in time. Mr Kemp said:
‘A moment in time of alleged safety does not a child safe make.’ 470
21.20. Only 114 Australian children were adopted in 2009-10 compared to more than 8,500
in the early 1970s. If Australian children in care were adopted at the same rate as in
England, there would have been 1,700 adoptions in Australia. If at the same rate as in
the United States, there would have been 4,800 adoptions in Australia. Permanent
removal to adoptive parents must have a place in South Australia’s child protection
system.
21.21. Child protection income management has been a tool at Families SA’s disposal since
2012, yet only one person has been subject to income management in that time. This
is because Families SA unnecessarily seeks the permission of the benefit recipient
before invoking income management, despite the fact that their child is at risk of
abuse or neglect. Very few people would consent to the discipline of income
management. Consent is unnecessary and creates an unnecessary impediment to the
wide use of income management. It should be used much more frequently, and the
nonsensical prerequisite of consent should be cast aside.
470
Transcript, page 2032
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21.22. Money provided by Government to the parents of children who are at risk of abuse or
neglect should not be spent on illicit drugs, alcohol, cigarettes or gambling. If such
parents are not already wasting Government benefits on such things, they have
nothing to fear from income management.
21.23. The law should be amended to provide that, with certain qualifications, a child born to
a person who has a conviction in respect of a child previously born to them for
manslaughter by criminal neglect, manslaughter or murder will, by force of the Act,
be placed from birth under the custody of the Minister.
22. Recommendations
22.1. Pursuant to Section 25(2) of the Coroners Act 2003 I am empowered to make
recommendations that in the opinion of the Court might prevent, or reduce the
likelihood of, a recurrence of an event similar to the event that was the subject of the
Inquest. I make the following recommendations directed to the Minister for Child
Protection Reform and the Minister for Education and Child Development.
22.2. I recommend that the Children’s Protection Act 1993 be amended to provide that a
child born to a person who has a conviction in respect of a child previously born to
them for manslaughter by criminal neglect, manslaughter or murder471 will, by force
of the Act, be placed from birth under the custody of the Minister. The Act would
then continue to apply to the child in the same way as if the custody had been ordered
by the court under section 38(1)(d), so that the parent might apply to the court for a
variation or revocation of the custody of the Minister. Furthermore, the Minister
would have the same powers in relation to the child as any other child under the
Minister’s care and protection: for example, the Minister might, by section 51(1)(a),
permit the child to remain in the care of some other member of the child’s family.
This might, for example, include the other parent of the child, who may have no
previous conviction in relation to children, and may be a suitable person to care for
the child. In such a case the Minister should be empowered to impose conditions on
the convicted parent’s dealings with the child, if the parents are still in a relationship.
That would alleviate the risk that the proposal might work an injustice upon a person
with no relevant conviction who happens to have a child with a person to whom the
471
The amendment should also include other forms of homicide not involving a conviction, for example, cases dealt with under
section 269 of the Criminal Law Consolidation Act.
153
section applies. The Minister would be able to place the child with that parent, if
satisfied that he or she was committed to ensuring that the child would be protected
from neglect or abuse at the hands of the convicted parent. The power vested in the
court to vary or revoke the Minister’s custody might be exercised in the convicted
parent’s favour in the event that they could establish to the court’s satisfaction that
they had changed their behaviours and attitudes so that the court could be satisfied
that they would not subject the child to abuse or neglect. The court might direct that
assessments and investigations be carried out by appropriate experts to assist it. By
this means the proposal would not prevent a person such as Ashlee Polkinghorne
being able to demonstrate that they had, with time, fundamentally changed.
22.3. I recommend that Families SA urgently re-educate all of its staff to rectify the
misunderstanding abroad in the organisation that questions to secure the protection of
a child cannot be asked of people without the permission of the child’s parent or
guardian. There is no such limitation, there never has been, and there never should
be. This message must be disseminated urgently within the organisation. It is
fundamental to the organisation’s responsibilities that its employees have a
questioning attitude and a curiosity to establish facts as to a child’s welfare. Without
this, Families SA cannot achieve its objectives.
22.4. I recommend that Families SA should strictly comply with section 20(2) of the
Children’s Protection Act with immediate effect. Furthermore, that the Minister for
Child Protection Reform draw the evidence of Mr Harrison and my remarks
concerning section 20(2) of the Act to the attention of the President of the Legislative
Council and the Speaker of the House of Assembly with the request from the
Coroner’s Court of South Australia that the President and the Speaker draw to the
attention of their respective Houses the flagrant disregard of section 20(2) by Families
SA.
22.5. I recommend that the Minister for Child Protection Reform investigate whether
Families SA have in any of its annual reports since 1 October 2006 reported on
compliance with section 20(2) of the Act in accordance with the understanding of the
Honourable Mr Xenophon MLC as referred to above. In the event that there has been
no such reporting, that fact should also be reported to the President and the Speaker
and an explanation provided.
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22.6. I recommend that Families SA direct its staff to actively apply child protection
income management in the Playford area of South Australia and that the ‘policy’ of
obtaining a benefit recipient’s consent to that course be abolished.
22.7. I recommend that the State Government take immediate steps to negotiate with the
Commonwealth Government for the declaring of areas other than the City of Playford
as declared areas for the imposition of child protection income management. There is
no sensible rationale for confining to one geographical area a tool which could have
the effect of benefitting many children at risk of neglect and abuse in this State who
happen to live outside of the geographical area of the City of Playford. It is absurd to
impose a geographical limitation of that kind in my opinion.
22.8. I recommend that the State Government begin negotiations with the Commonwealth
Government with a view to making the child protection income management regime a
permanent structure and to that end, negotiate an indefinite extension beyond 30 June
2015 which is when the present Bilateral Agreement expires.
22.9. I recommend that Families SA issue a policy prohibiting the transport alone of a child
under the age of 12 years in any circumstances with a chauffeured delivery service
unless in the custody of an employee of Families SA.
22.10. I recommend that the operations of the Crisis Response Unit be reviewed with a view
to determining whether it has sufficient resources and there is sufficient backup for
situations such as that faced by Ms Heading on 12 November 2008. Ms Heading
appeared to have a reluctance to call in a worker who may have been ‘on-call’. There
should be no such reluctance in a situation such as that being faced by Ms Heading.
There should be no hesitation in arranging a call back for an on-call worker in a case
such as that. I am concerned that there may be a reluctance on the part of a person in
Ms Heading’s position to institute a call back because of financial considerations.
Staff should be informed as a matter of policy that the appropriate action is to institute
a call back in a situation such as that faced by Ms Heading. There should be no doubt
at all about this and I recommend accordingly.
22.11. I recommend that the Children’s Protection Act 1993 be amended to include
cumulative harm as a relevant factor in making decisions about the care of a child.
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22.12. I recommend that the Children’s Protection Act 1993 be amended to make it plain that
the paramount consideration is to keep children safe from harm. Maintaining the
child in her or his family must give way to the child’s safety.
22.13. It is my opinion that adoption should have a place in the alternative placement options
in the child protection system. I do not purport to be in a position to offer a settled
model of what the role of adoption in the child protection system should look like.
However, the evidence of the scarcity of alternative placement options and the
notorious under supply of suitable and willing foster parents leads me to the very firm
opinion that permanent removal to adoptive parents must have a place in the child
protection system and I recommend accordingly.
22.14. I recommend that a proper assessment be undertaken to ascertain the most effective
resource allocation method for Families SA. That assessment should include, as a
starting point, a consideration of the volumes of work and what resource effort is
needed to carry out that work satisfactorily. There must be an ability to monitor
unfinished work and a system to measure the performance of individuals and the
individual parts of the agency and there must be a reliable system for reporting those
measurements in a timely manner to managers right up to the chief executive.
22.15. I recommend that the evidence of Anthony Kemp, as a whole, be considered and
included as a part of the redesign process referred to by Mr Harrison in his evidence.
22.16. I recommend that Families SA allocate cases to dedicated workers to ensure
continuity of care in the management of children at risk.
22.17. I recommend that Families SA train social workers in the art of proper note taking,
with emphasis on the need to be factually accurate, and make a clear distinction
between the facts of an event and the worker’s opinions and judgements about the
event and particular individuals.
22.18. I recommend that Families SA does not close files on their computer system when
they are still in fact involved with the management of a file.
22.19. I recommend that when Families SA becomes aware of the involvement of another
agency with a client, an accurate summary document is provided to the agency setting
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out relevant information about the client to ensure the agency is properly equipped to
assist in ensuring the safety of any children under that client’s care.
22.20. I recommend that domestic violence counselling be implemented in all circumstances
where Families SA identifies it as a risk factor for a client and that a failure to
participate in domestic violence counselling be recorded for adverse consideration
when assessing the onward progress of the care of a child.
22.21. I recommend that a measure be introduced which provides for registration of social
workers.
22.22. I recommend that there be a mandatory restriction on student social workers and
qualified social workers with less than 12 months experience having client contact
without direct supervision by a senior social worker.
Key Words: Child Abuse; Child Protection; Families SA (Department of Education and
Child Development); Domestic Violence
In witness whereof the said Coroner has hereunto set and subscribed his hand and
Seal the 9th day of April, 2015.
State Coroner
Inquest Number 17/2014 (0114/2012)
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ANNEXURE 1 – Persons referred to in the Finding