A NSW coroner has directed 17 recommendations at several organisations after a five-year-old was drowned by his mother in the Murray River.
The mother was found not guilty of murder in the NSW Supreme Court by way of mental illness based on unanimous expert evidence in 2017.
An inquest in Deniliquin in May 2021 examined 28 key issues focusing on the organisations and agencies the mother was involved in, and potential shortcomings and inadequacies.
Coroner Teresa O'Sullivan in Lidcombe Coroners Court on Friday said the child was clearly a much-loved younger brother and adored by his grandparents.
"He was described as full of life from an early age, loved to play games and attend the local park ... very outgoing and always carried a toy truck or ball," Ms O'Sullivan said in delivering her findings.
She concluded that the child died at about 6.15pm on March 2, 2017 due to the acts of his mother, and made 17 recommendations.
They are directed to NSW Police Commissioner, Victoria Police Chief Commissioner, the NSW Department of Communities and Justice, Murrumbidgee Local Health District and the Catholic Education Office.
The mother , 27, had taken her two sons aged five and nine to the Murray River at Moama west of Albury, and across the border from Echuca in Victoria.
The undisputed evidence at her Supreme Court trial was that she caused the death of her youngest son by holding his head underwater and drowning him.
According to the judgment, she made a concerted effort to do the same to her older son but he managed to escape.
In closing the inquest the coroner offered her sincere condolences to the late child's family, saying his grandmother displayed enormous dignity, courage and strength in giving evidence.
