Victoria's Child Protection Service (CPS) is being placed under the spotlight at a coronial inquest examining the deaths of three murdered children and a toddler who died of blunt force trauma.
The children — who were aged between six months and 15 years at the time of their deaths — are unrelated, except for the fact they had some involvement with the state's CPS.
Over the course of the inquest, the Coroners Court will examine the services provided to the families, their involvement with the CPS and any systemic issues within child protection in Victoria.
Child One
Child One was two-and-a-half-years-old when she died.
Prior to her death, there had been six notifications made to the CPS about her family.
They included concerns about physical discipline by her parents, the mother's parenting capability and the children's exposure to family violence.
At some point, the mother notified the CPS of her relationship with a new partner — a criminal history check found he had an extensive criminal history, including for family violence.
CPS closed its involvement in July 2015, after noting the mother's engagement with recommended support services.
In late August, Child One's body was found by police.
Her cause of death was found to be the result of internal blood loss associated with blunt force trauma.
The woman's partner was arrested and tried for murder, but was acquitted in 2016.
Child Two
Two reports were made to child protection when Child Two's mother was pregnant with him.
The first concerned her ability to provide adequate care for him, while the second report alleged she was a drug user, had a gambling addiction and was homeless.
A month before he was born, a social worker contacted the CPS and arranged a pre-birth meeting.
By the time Child Two was born, in December 2015, the CPS "had neither met with the mother nor undertaken a pre-birth meeting with her to determine future steps".
A month later, in January 2016, the CPS referred her to a support program. She did not engage until April.
Nevertheless, the CPS closed the case, as the mother was willing to engage with the program, and the original concerns were recorded as being unsubstantiated.
Days later, there were two more notifications made about the mother, which were assessed as "indicating a significant and immediate risk of harm" to Child Two.
That same month, his mother began a relationship with a new man. He was subject to two community corrections orders.
In June, after smoking methylamphetamine, the mother left her child with her new partner. He later called her to say her son was not breathing.
Child Two died at just six months of age.
The mother's partner was later charged and found guilty of murder. He was sentenced to 34 years in prison, with a non-parole period of 27 years.
Child Three
Child Three was born in 2001 — the reports to the CPS in relation to her and her siblings date back to that year.
They related to various concerns, including parental drug use, mental health issues, family violence, homelessness and sexual abuse.
In 2012, she was removed from her mother's care and did not have contact with her again until 2015. At the time of her death, she was still in foster care.
Her mother, meanwhile, had started and ended a relationship with another man.
During their relationship, two reports were made to Victoria Police about family violence, while additional documents reveal he began making threats to her mother in public.
The last known threat was in February 2017, when he told a friend he would burn her.
In February 2017, Child Three went to stay with her mother and ceased contact with her carer.
A week later, the mother's former partner set fire to the alcove where they were staying.
Child Three died, aged 15, along with her mother and her mother's new partner.
The perpetrator pleaded guilty to all three murders and was sentenced to 30 years in prison, with a non-parole period of 24 years.
Child Four
Child Four's mother struggled with mental health issues and episodes of psychosis following the birth of her children. She had multiple inpatient psychiatric admissions in 2013, 2015 and 2016.
During these episodes, she had delusional and paranoid thoughts, including that her family was conspiring to kill her. She also became aggressive.
Between 2013 and mid-May 2017, five reports were made to the CPS ahead of Child Four's death. All reports, aside from the first, were closed at the intake phase.
In June 2017, when she was caring for her four children, the mother contacted her husband, telling him she thought Child Four was dead and that she had stabbed him.
In 2018, the mother was sentenced to a 30-month community correction order with conditions about her mental assessment.
The inquest, which began on Monday, will run for two weeks and resume again later in the year.