A coroner has identified a series of failings in the care provided to a 16-year-old girl who died of a drug overdose while in the custody of Victoria's Department of Health and Human Services.
Coroner Audrey Jamieson also sharply criticised the actions of staff at the Salvation Army's Westcare agency, which was contracted by the department to care for the girl, who was suffering from a complex combination of substance abuse and mental health issues.
However, Ms Jamieson said she was unable to definitively say that Maria Liordos would have survived if Westcare staff had acted differently on the night she died.
An inquest last year heard that Maria was under the influence of a cocktail of drugs when she left her St Albans residential care unit, in Melbourne's north-west, on September 23, 2013. She went to the nearby house of a male acquaintance with a girlfriend, who found her dead the next morning.
The sole staff member on duty at the unit that night phoned Maria's Westcare case manager, Michelle Hines, to tell her Maria was drug-affected and to ask what she should do. They also discussed whether an ambulance should be sent to the house Maria had gone to, but an ambulance was not called.
At the inquest, Ms Hines claimed she had called the department's out-of-hours child protection line to try to obtain a warrant for Maria's return. But Ms Jamieson's findings said phone records suggested that was false.
"Her interpretation of the events appeared self-serving, could not be substantiated and did not stand up to scrutiny such that I was prompted to remind her of the requirement to tell the truth under oath," Ms Jamieson said of Ms Hines.
Ms Jamieson also stated that Ms Hines was aware of the identity and home address of the man whose house Maria died in, but made no checks or inquiries about whether it was suitable for Maria to associate with him.
"There is a dearth of evidence that she took any meaningful action to keep Maria safe on the night," Ms Jamieson said.
"Ms Hines was employed by Westcare. I do not suggest that they condone the behaviours or inactions of their employee … however, they cannot divest themselves of responsibility."
The coroner said there was a "significant loss of opportunity" when the Westcare staff did not try to get Maria to undergo medical "monitoring" on the night before her death. The staff members were unaware of an "action plan" drawn up for Maria in the event she was under the influence of drugs, which recommended calling an ambulance, and therefore did not act on it.
Evidence 'reflects badly' on DHHS
The inquest also revealed a lack of oversight of Westcare by the department
"Both organisations failed to achieve any of the significant goals for Maria, including reunification with her family, reform and rehabilitation of her substance misuse, and significantly to keep her safe from own behaviours," Ms Jamieson wrote.
"The DHHS failed to properly monitor Westcare's delivery of services to Maria.
"The evidence in this regard reflects badly on the DHHS.
"The Department cannot totally divest itself of its responsibilities to the state's most vulnerable children merely by contracting the delivery of intensive case management to another agency.
"However, I find these issues are not directly causative to Maria's death."
The coroner made three recommendations:
- A review of the after hours child protection emergency service
- Agency workers be given a dedicated, direct phone line to access the department after hours
- Agency workers be given new tools for the detection and apprehension of high-risk children, including a red flag system on the Victoria Police LEAP database
Ms Jamieson said other recommendations had already been reflected in changes made by Westcare after Maria's death.
Outside the Coroner's Court, Maria's mother, Sue Liordos, said there needed to be greater scrutiny of both the department and the private organisations it contracts to look after the state's most vulnerable children.
"My aim has always been to highlight all the inefficiencies and deficiencies of the system and for ultimately changes to be made so that someone else doesn't lose a child in care," Ms Liordos said.
"What worries me though, and I base this on my experience of both DHHS and Westcare, is that they may make changes, they might put them down in black and white, but … what independent person is going to be there to make sure that they actually implement them, so that this doesn't happen again?"
Representatives of the Salvation Army refused to comment outside the court.
The department has been approached for comment.
Victoria's residential care system, which houses hundreds of the state's most vulnerable children, has been dogged in recent years by reports of sexual and physical abuse perpetrated by carers, other children and people outside the system.
Some agencies that operate the units have been criticised by parents, carers, children and others over the standard of care they provide, but they in turn have claimed to be underfunded by the State Government.
The Government has promised to decrease the number of children in the system, and to introduce "therapeutic care" in all units, which will tackle the underlying traumas suffered by many of these children.