WARNING: The content of this story may cause distress
- Deputy state coroner Jane Bentley says Child Safety failed to protect Mason Jet Lee from serious harm
- She says Mason should have been removed from the care of his mother and stepfather
- The 21-month-old boy died from peritonitis after being punched so hard his intestines ruptured
The handling of Caboolture toddler Mason Jet Lee's case was a "failure in nearly every possible way" by Queensland Child Safety staff, a coroner's damning report into his death has found.
Mason was only 21 months old when he was found dead in a Caboolture home — days after being punched in the stomach by his mother's then-partner in June 2016.
The boy's stepfather, William O'Sullivan, and mother, Anne-Maree Lee, were jailed for manslaughter and child cruelty.
Handing down her findings in Brisbane on Tuesday, deputy state coroner Jane Bentley's report said the Department of Child Safety failed in its duty to protect the little boy from "the risk of serious harm he faced in the months prior to his death".
"Indeed, it is difficult to find any step taken in this case that was carried out in accordance with policies and procedures and correctly documented," she said.
She said Mason should have been seen face-to-face 12 times between March 15 and and June 11, 2016 but instead was only seen once, for about five minutes.
"Had it been known that he was living with [his stepfather] and had his history been considered, he should have been removed from the care of his mother and [stepfather].
"The department accepts that there was an obvious failure to sight Mason as required and that this is a fundamental requirement of child protection."
Ms Bentley said the day before Mason's death, a neighbour told a Child Safety officer that Mr O'Sullivan was dangerous and violent, and was holding Mason hostage, but the employee took no action to assess Mason's safety and "went home".
That staff member then told a colleague, who similarly took no action and "didn't consider it any further".
Ms Bentley found Mason's treatment and management by Queensland Health was appropriate and made no adverse findings against the Queensland Police Service (QPS).
She said it was concerning that when QPS requested a copy of the department's file on the Lee family in April and May 2016, the department provided a redacted version "which was missing relevant information".
Ms Bentley said the Ethical Standards Unit had determined 21 employees of the department, involved in Mason's case, had failed to carry out their duties appropriately.
"[That] is indicative of the scale of the failure," she said.
Ms Bentley acknowledged the department and the State Government had taken "comprehensive" steps to investigate Mason's death and that many reforms had been made.
She made no recommendations about the department's failure to sight Mason because it has always been a fundamental aspect — and a requirement — of child protection, noting a predictive planning tool has since been introduced.
However, she recommended the sharing of information between the department and QPS be reviewed and monitored.
She also recommended that the Suspected Child Abuse and Neglect manual and policies be amended to require that cases remain open until appropriate feedback has been provided and it has been agreed that recommendations have been fulfilled or no longer appropriate.
"The above recommendation was suggested by Queensland Health and is supported by the department," she said.
Ms Bentley said the Department of Health should implement formal policies and procedures for a case to be escalated where medical officers disagree with a decision made by the department in relation to a child being discharged from hospital.
She also urged the department to review its policies and procedures to ensure that adoption is "routinely and genuinely" considered as an suitable permanency option for children in out-of-home care.
Ahead of her findings being delivered, Ms Bentley told the court: "If Mason had to endure these things, then we as a community should be aware of [it]."
Slow and 'unimaginably painful' death
Next week marks four years since the toddler's bruised body was found in a home at Caboolture, north of Brisbane after suffering a slow and "unimaginably painful" death.
He had been punched in the stomach by his stepfather William O'Sullivan so hard that it ruptured the boy's intestines, leading to peritonitis.
By the time he turned one, Mason was already known to Child Safety.
When the boy's short life came to an end almost 10 months later — the outcry led to a major reform of the department following multiple reviews and staff being stood down.
The court had previously heard the little boy's death could have been prevented with proper medical help, but neither O'Sullivan nor Mason's mother, who lived about a kilometre away, sought care for him as his condition deteriorated.
The deputy's state coroner's findings come at a time when the system is again under scrutiny following the death of four-year-old Willow Dunn and the discovery of two teenagers locked inside a home in squalid conditions.
Mason was 'hidden from view'
At a pre-inquest conference late last year, counsel assisting Dr Jacoba Brasch QC said the inquest was not about "vengeance or blame", but identifying whether those tasked with protecting children could "be better assisted".
Details around the family's interactions with Child Safety staff were laid bare during the inquest, which had to stop hearing oral evidence in open court midway through because of the coronavirus pandemic.
In tendered documents released by the court, one expert who specialised in decision-making in child protection services noted that Mason was to a large extent — "hidden from view".
"He was rarely seen, and it appears that his bedroom was not seen by a Child Safety worker," the specialist's report stated.
The specialist stated it had not appeared that workers viewed Mason's home beyond the main living areas in any of the home visits made.
"This would suggest that there was a lack of curiosity, and assumptions made that if the shared areas of the home were acceptable, the whole [home] would be.
"Mason was on the periphery of workers' attention, rather than at the centre."
He said although Mason's "hiddenness" could seem surprising, the relative invisibility of children in home visits and case recording was a common issue in other studies.
The specialist said Child Safety workers focused their attention too heavily on Mason's mother Anne-Maree Lee as a victim, rather than the child himself.
'Sophisticated forms of deceptive behaviour'
Ms Lee, who was known to child protective services herself as a child, was viewed by staff as "open and willing to engage", a "victim" and a "survivor".
"Ms Lee had framed the situation with herself as 'victim' rather than Mason, diverting blame from herself and attention away from him," the report said.
"When a less experienced worker was asked to do a safety check, she misinterpreted this to refer to the mother rather than the children.
"When asked why she did not ask the mother about Mason's whereabouts, she replied that she had assumed that he was sleeping or in day care."
He also said there was evidence Lee and O'Sullivan engaged in "sophisticated forms of deceptive behaviour" to divert attention from the core issues.
A statement by one police officer detailed the difficulties the Queensland Police Service had dealing with the Child Safety Department.
The officer stated a free flow of relevant information between the two entities "did not exist" and an investigating officer had to obtain two search warrants for the release of information from the department.
The police officer said this seemed to "fly in the face" of the intent of joint investigations and information sharing.
One doctor also expressed frustration to the inquest that concerns about neglect sometimes "got lost in translation" and had not always got down to the frontline workers.
According to documents tendered to the inquest, Mason became known to the department on July 25, 2015, when concerns about his care were raised.
On June 9, 2016, an "intervention with parental agreement" case was formally opened for Mason, a report said.
The boy was discovered dead two days later.
In a tendered statement, a department employee said child protection practice was a "complex area" and families had significant needs.
"Mason's death occurred at a developmental time of significant system and practice reform, stemming from the Carmody Inquiry  and this work continues now," the statement said.
As of November last year, 66 per cent of households with substantiated harm or risk of harm to a child had a parent with a current or past drug/alcohol problem.
All five of the department's "primary parent risk factors" — domestic violence, drug and alcohol abuse, parent experience of abuse or neglect as a child, mental illness and criminal history — were present for Mason's family's case, another employee said.
A 2016 KPMG review found the North Coast region, which took in Caboolture, "suffered a growing demand", leading to high workload pressure.
According to a tendered document released by the court, after the little boy's death, the Ethical Standards Unit (ESU) investigated nine departmental officers.
The statement said ESU substantiated allegations against eight of them, with three choosing to leave the department before the investigation was finished.
One of those officers was also referred to the Crime and Corruption Commission (CCC) for professional misconduct, however, no further action was taken because they had left.
The other five were reprimanded.