The deaths of two Queensland sisters in a hot car was an "avoidable" tragedy and the child protection system "should have done more" to promote their safety, a damning review has found.
WARNING: This story contains content that readers may find distressing.
The ABC has obtained a copy of the Queensland Family and Child Commission (QFCC) report, which found the child safety department did not put enough safeguards in place, overlooked "clear red flags" before their deaths, and there was a lack of information-sharing across agencies.
It also said staff "focused on the motivations of those who reported concerns", rather than on the safety of the girls.
Darcey-Helen, 2, and her sister Chloe-Ann, 1, died after their mother Kerri-Ann Conley left them in the car for nine hours in November, 2019. Temperatures inside the vehicle exceeded 60 degrees Celsius.
Last month Conley was sentenced to nine years' jail after pleading guilty to their manslaughter.
The Queensland government has released a summary version of the QFCC report and its response to its findings.
The QFCC report quoted by the ABC was prepared for the government. The tabled document is a de-identified summary of that report.
The ABC's Background Briefing podcast last month revealed the repeated warnings to the department of child safety by Darcey's father, Peter Jackson, in the weeks leading up to the toddlers' deaths.
In 2019, Queensland's attorney-general asked the QFCC to examine the system's response prior to the the girls' deaths and to identify opportunities for improvement.
The report said the sisters' young age made them "particularly vulnerable".
"They relied entirely on their mother to care for them and to keep them safe and on the system to intervene when she was unable to meet their care and protection needs," the report said.
"This review found the child and family support system should have done more to promote the safety of Darcey-Helen and Chloe-Ann."
Soon after Darcey-Helen was born in 2017, she came to the attention of child safety authorities.
"Concerns were raised about her family's vulnerabilities and her mother's crystal methamphetamine (ice) use and potential neglect of Darcey-Helen while she was coming down from its effects," the report said.
The department opened an intervention with parental agreement (IPA) – which allows child safety officers to work with the parents while the child remains in the family home.
But, the report said, Conley was "frequently non-compliant" with intervention requirements, leading the department to put Darcey-Helen in foster care on a short-term arrangement with her mother's consent.
After she returned to her mother's care, the department put a safety plan in place.
"However no case plan was developed, and her mother was not held accountable for addressing the risk her behaviours posed to the baby," the report said.
"Despite child safety's policies and procedures, safety and case planning requirements were not met appropriately or effectively."
A case plan was eventually developed.
Work load of child safety officers an issue
In mid-2018 – three months before Chloe-Ann was born – child safety closed the IPA after Conley withdrew her consent.
This was despite the mother not having completed or complied with case plan actions and ongoing disclosures from friends and family about her substance misuse, the report said.
"While it is clear the IPA with the Conley family was not managed well, the extent to which this is occurring with other families on current interventions is not clear. This must be quickly established," the report said.
The ABC Background Briefing program last month aired concerns by a child safety officer who worked with Darcey and Conley who spoke about her crippling caseload.
The officer said she may have been able to prevent the girls' deaths if she was not so overloaded, with a workload of up to 22 children.
The QFCC report also found there was an incomplete or lack of information-sharing across agencies in the Conley case.
The Queensland Police Service failed to provide details about Conley's alleged drug dealing and drug use with the department when it requested information when closing the case.
"The sisters' mother did not receive any health-based supports or treatments to help resolve her ice use," the report said.
"The family continued to be referred to secondary service supports, despite the children's mother either disengaging or not engaging with these.
"Information relating to concerns for the children were not shared with child safety by the Queensland Police Service and Queensland Health when they should have been."
Failure to act on concerns
In the weeks before they died, people contacted the department with concerns about the children, "mainly about their mother using ice and dealing drugs".
"Child Safety considered those reports stemmed from a 'custody dispute' and did not view the information as credible," the report said.
Three reports were made – one from a doctor who had received information from another source and two community members.
The ABC has previously revealed that three weeks before the girls died, Darcey's father reported to child safety that Chloe had been left in the car by her mother for hours overnight.
He and a doctor also reported concerns that the girls had been exposed to methamphetamines at their mother's house.
"Despite the history of previous concerns of neglect and parental ice use, child safety considered that the information received did not suggest the children were in need of protection because the information was thought to be motivated by a custody dispute, and the original source of the allegations was considered to be unreliable," the report said.
"Despite having no contact with the family since before 13-month Chloe Ann's birth, child safety considered there was no evidence to support the concerns the mother was using drugs and there were no concerns about drug use."
Child safety again referred the family to a secondary service.
The QFCC said it was not appropriate for the system to focus on assessing the motivations of the reporter, instead of the risk of harm to the child.
"[It] meant child safety did not assess the family's child protection history, known experiences and vulnerabilities," the report said.
"As a result, it did not make an informed decision about the safety of Darcey-Helen and Chloe-Ann."
The report noted previous QFCC system reviews have found that organisations focus on the motivations of a notifier rather than on the safety of children.
Review of IPAs completed
The QFCC review made a number of recommendations.
They included that the department take immediate action to eliminate "practice non-compliance" within the Child Safety Service Centre that dealt with the Conley case to make sure all children on current IPAs are safe.
It also recommended the QFCC immediately launch its own broader review into the safety of children during interventions with parental agreements, with a sample of cases across the state.
In its tabled response, the government said the death or serious harm of any child is a tragedy, it accepted all three recommendations made by the QFCC, and has already implemented them in full or in part.
It said the department undertook a compliance audit of the Logan Child Safety Service Centre and has now reviewed and updated the practice guidance for all staff regarding IPA cases.
The QFCC has also released its report on the review of IPAs.
Principal Commissioner Luke Twyford said it demonstrated there are "continuing risks and inherent risks in child safety decision making when we elect to leave a child in the family home, where we have evidence that there are historical risks".
"Both reports we have produced show that information sharing is fundamental to increasing the safety of children," he said.
Department has taken 'significant action', minister says
Minister for Children Leanne Linard said the girls' death was a tragedy but declined to say whether she accepted their deaths could have been prevented.
She said she was limited in what she could say under the Child Protection Act.
"What I absolutely accept is that our oversight bodies, the QFCC who have completed a review found that there were areas for improvement," she said.
"Those three recommendations are contained in the report that has been tabled today ... and the response to that outlines the significant following actions the department has taken to address those issues."
She said there will "always be room for the system to improve".
