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Four Corners -

View in ParlView

Reporter: Quentin McDermott

Date: 08/11/2010

QUENTIN McDERMOTT: As darkness cloaked this desolate stretch of road five years ago, a woman
steered her car onto the verge and settled down with her children to sleep. It was a bitterly cold
winter's night.

The next morning her children woke up ravenous. Uncharacteristically, their mother dressed them
smartly, braided her hair, and drove into the car-park at this country road house.

DOT ORDELMAN: These little children looked like little elves. They really tiny pinched faces and
that, but they were beautifully dressed and that, but they were hungry.

QUENTIN McDERMOTT: Just how hungry the children really were was not immediately apparent.

It was only when the mother produced her newborn baby that the awful truth dawned on staff at the
roadhouse. The baby boy had died from malnutrition.

DR ALLAN CALA: The child did not survive because he was deprived of sufficient calories for growth
and development.

QUENTIN McDERMOTT: So essentially he starved to death?

DR ALLAN CALA: In a nutshell, that's what happened to this child.

DOT ORDELMAN: I just can't imagine that you would let a child starve to death. Just the fact that
that baby would've been crying until it got too weak to cry. But how do you do that? I just, no I
can't, I, I hope I never see anything like it again in my life, um, because it was horrible.

QUENTIN McDERMOTT: In Australia today, hundreds of thousands of children are born into loving,
caring families. But others are dying from neglect. Legal restrictions on identifying children in
care mean that few of these stories receive the publicity they deserve.

Tonight we break through this barrier of silence to describe in detail how two children died from
appalling neglect, and how if our child protection services had been better, their lives would
almost certainly have been saved.

Tonight on Four Corners, stories of the children who died, and the system that failed to protect


QUENTIN McDERMOTT: For many Australians, visiting Alice Springs carries with it all the romance of
the Red Centre.

But for some, growing up in the town is an ordeal.

This youngster, who is now eighteen, survived a violent, abusive childhood in the Northern
Territory. For legal reasons he can't be identified.

SON: My mum was a drug addict. Um, there were some points in my life where I had to look after the
kids and help out. It was mainly more when my stepdad was around, he was quite violent towards my
mum, but then he also didn't like me being around the kids.

QUENTIN McDERMOTT: Ten years ago when he was eight years old, his step-father was reported to the
Northern Territory's child protection authorities, known then as NT Families and Children, or FACS.

(To son): You told them that your stepdad was violent towards you and that he'd thrown you across
the room and punched you. Do you remember that?

SON: Yep he went to gaol for it.

FORMER DET. SGT ANNE LADE: He was actually charged and convicted of assault and there was another
incident where um, in fact FACS workers um witnessed ah, the step-son being abused by the mother
and at that time he was taken from the mother for a period of months.

QUENTIN McDERMOTT: The young boy spent fourteen months in foster care. When he rejoined his family,
he and his siblings lived in the hotels and motels of Alice Springs and sometimes slept in the car.

Maxine Scott was a friend of his mother's and knew the children well.

MAXINE SCOTT: Their clothes were never washed. They've never had baths unless they came to my
place, yeah, they were always around the streets you know, with dirty clothes on.

QUENTIN McDERMOTT: The mother had a big family, and soon after giving birth to her fifth child, a
girl, she invited her friends to a barbecue at this motel, where they were staying.

Maxine Scott went to have a look at the baby in one of the rooms.

MAXINE SCOTT: The baby was on the bed and everyone was outside where the barbecues were and I took
the blankets off the baby and that and saw the state it was in. It was just skin and bone when I
picked it up. It couldn't even cry. It wouldn't suckle a thumb or a finger from me or anything. It
was floppy, yeah.

QUENTIN McDERMOTT: Maxine Scott acted on her instincts. She picked the baby up and took her to the
police. But they didn't want to know.

MAXINE SCOTT: I went to the police station and said you know, I needed help and that and um the
police said to me, if I didn't take the baby back I was going to be held up for kidnapping, and so
I took the baby back. And then I went back to a phone box and started ringing FACS and that and got
no response until the next morning when I went to work and I rang them again. And it was about two
days later that they actually grabbed the baby.

QUENTIN McDERMOTT: Child protection workers who seized the baby girl said she looked 'like a
skeleton with skin stretched across her face'.

Three months after her birth, she weighed half a kilo less than when she was born. In order to
ensure she would now be properly cared for, the baby was handed over to foster parents.

But shortly afterwards, the mother fell pregnant again.

MAXINE SCOTT: It surprised me because yeah, we never knew that she was pregnant and she just popped
these kids out, yeah.

QUENTIN McDERMOTT: Why do you think she had so many children?

MAXINE SCOTT: I think it was just for the money.

QUENTIN McDERMOTT: The welfare money?


QUENTIN McDERMOTT: What did she spend the money on?

MAXINE SCOTT: Mainly drugs, yeah...

QUENTIN McDERMOTT: And injecting drugs?


QUENTIN McDERMOTT: The child protection authorities knew the mother was a drug addict. But despite
this, they arranged for the baby girl who she had nearly starved to death, to be given back to her.

(To Former Det Sgt Anne Lade): Did that surprise you?

FORMER DET. SGT ANNE LADE: It does yes, considering the whole picture of all that was going on and
all that was happening with the children it did surprise me, yes.

QUENTIN McDERMOTT: Several eyewitnesses told FACS, the child protection authority, that the mother
was continuing to harm her little daughter. Maxine Scott says she even saw bite marks on the little

(To Maxine Scott): They were on her back, on her arm and there was one on her face as well, yeah.

QUENTIN McDERMOTT: Did you ask the mother where the bite marks came from?


QUENTIN McDERMOTT: And what did she say?

MAXINE SCOTT: She said that she bit her, bit the little girl because the little girl had bitten the
other children and that was punishment.

(To Dr Terence Donald): Here was a mother who it was alleged ah, was brutalising her own children,
hitting them, biting them and in the case of a little girl, half starving her to death. What should
have happened in that mother's case?

DR TERENCE DONALD, FORENSIC PAEDIATRICIAN, SA: These children needed to be seen. They should have
been seen many times by um, jointly by police and community services. There should have been an
opportunity for somebody with proper forensic knowledge to examine the children and talk about what
the injuries were and what could have caused them. If that had happened then the family would have
been able to have been assisted.

QUENTIN McDERMOTT: But this didn't happen. In 2005 the mother gave birth to her seventh child, a

At birth, he weighed a healthy three point four kilos. But two hours later, without waiting for his
neonatal screening to take place, the mother took her baby and fled the hospital.

For the next eight days, midwives from the hospital pursued the mother, making repeated attempts to
weigh the baby boy and monitor his progress.

Three times they succeeded, but each time the baby weighed less than when he was born.

(To Maxine Scott): How did the baby seem?

MAXINE SCOTT: The baby was very skinny as well.

QUENTIN McDERMOTT: Did the baby's condition remind you of the little girl?

MAXINE SCOTT: Yes, it did.

QUENTIN McDERMOTT: So what did you do?

MAXINE SCOTT: Um, once again I rang FACS again, reported it and um, yeah.

QUENTIN McDERMOTT: At this point case-workers from FACS took up the chase. It lasted for weeks and
would end disastrously.

Astonishingly, when FACS' case-workers finally caught up with the mother in an Alice Springs
shopping centre, they let her go, following a furious argument.

FORMER DET. SGT ANNE LADE: They attended with um, uniformed police officers a-as a as a back-up.
There was a discussion with the mother about taking the baby to the hospital to be checked up on.
Um, the mother was not happy at that happening. Um, she spoke with a senior FACS worker on the
telephone and an arrangement was come to that she said that she would come to the FACS office in 20
minutes and bring the baby and so as a result of that um, the FACS workers who were present agreed
to let her go um, but she didn't turn up with the baby.

QUENTIN McDERMOTT: Soon afterwards, the mother took her four youngest children and drove to
Melbourne to pick up her eldest son, who was staying there.

By now, child protection workers were desperate to track her down and locate the baby.

On Friday the 27th of May 2005, frantic efforts were made by an after-hours worker here at FACS in
Alice Springs to get her counterparts in Victoria to find the baby boy and his mother before it was
too late. But the after-hours worker here couldn't access the information she was being asked for,
and her boss, the child protection manager for Alice Springs, had turned her phone off for the
weekend. Not only that, there was no interstate police alert put out because of a communications
breakdown between two senior staff in the Northern Territory. The little baby boy was now in mortal

(To son): Who could've stopped it happening?

SON: FACS, the Alice Springs police. There were many people that saw my brother. There were many
people that knew she was coming to Melbourne. There was many people that knew where she was. On the
way there was many people that were in contact with her at different points in time.

QUENTIN McDERMOTT: When she arrived in Melbourne, the mother picked up her eldest son and started
on the long road back to Alice Springs. For the next three nights, the mother and her five children
slept together in the car. By now the baby boy was close to death and when they pulled into Port
Wakefield, north of Adelaide on the morning of June the 1st, it was too late.

Dot Ordelman used to work in the road house kitchen. The memory of that morning will stay with her
forever. At 8.40am, a woman came into the road house asking where the nearest pawnbroker was. With
her was a little girl.

DOT ORDELMAN: This child was standing in front of a fridge with jellies, cheesecakes and
sandwiches, but the child was crying for a sandwich and as she walked out, the penny dropped and we
realised the child is hungry and she hasn't got any money obviously.

QUENTIN McDERMOTT: Outside, the woman was standing with her baby wrapped in a blanket.

DOT ORDELMAN: She says my baby is not breathing and um, I took a look at the baby and well felt its
cheek, tried to hold its fingers, but it was cold and I knew there wasn't really anything I could
do. I took the baby blanket from around him and he looked like a little, he had the most little
elfin pinched face and it was just so sad. He was so tiny.

QUENTIN McDERMOTT: The mother was arrested and her other children taken into care.

Dr Allan Cala performed an autopsy. Seven weeks after his birth, the baby weighed a kilo less than
when he was born. Less than half the normal weight for a child of his age, and there were no
extraneous conditions which could have explained this.

DR ALLAN CALA: The cause of death I believed was failure to thrive due to caloric insufficiency.

QUENTIN McDERMOTT: That's a euphemism really, isn't it?

DR ALLAN CALA: Yes, ah that's right. Essentially it looked to me as if this child essentially had
starved or had died of malnutrition.

QUENTIN McDERMOTT: Why did she do it? Why did she starve her little boy to death?

SON: I don't believe that it was something she consciously or deliberately did.

(Footage from police tape)

OFFICER: The time is now 14 minutes past 10pm on Friday the 5th of May, 2006 and we're located at
the upstairs interview room of the Alice Springs Police Station...

(End of footage)

QUENTIN McDERMOTT: Following the baby's death, Northern Territory police questioned the mother
about her failure to properly care for her children.

In this interview, which has never been shown before, they focussed on the way she had treated her

(Footage from police tape)

OFFICER: Did the doctors explain to you what could happen to a child that's, that was in a state
that (name of girl) was in at that time?


OFFICER: Yeah. What did they tell you?


OFFICER: What did they say to you?

MOTHER: That she would die.

OFFICER: Okay. And did they tell you what it was, why she was underweight, what they attributed it
to being?

MOTHER: They said it was, um, failure to thrive...

OFFICER: Failure to what?

MOTHER: Failure to thrive or something.

(End of footage)

QUENTIN McDERMOTT: In 2006, the mother pleaded guilty to the manslaughter of her baby boy. The
South Australian court heard that she suffered from borderline personality disorder.

She was sent to jail for ten and a half years, but the sentence was reduced on appeal to seven and
a half years.

SON: I don't blame my mum for what happened. I know she's in gaol for what happened and she did the
wrong thing.

QUENTIN McDERMOTT: Why don't you blame her?

SON: Because there was obviously a lot of stuff going on then and FACS should've stepped in and so
I blame them. Because even though it is my mum's fault, they had the opportunity to stop it and
they didn't.

(To Former Det. Sgt Anne Lade): Should FACS and could FACS have done a great deal more?

FORMER DET. SGT ANNE LADE: Yes. I, I, they should have and they could have. With the history that
this woman had with um, all of her children, um I, I think FACS could have and should have stepped
in a lot earlier.

QUENTIN McDERMOTT: So was this baby's death preventable?

FORMER DET. SGT ANNE LADE: I believe so, yes.

QUENTIN McDERMOTT: The tragic and preventable death of the seven-week-old baby boy is one example
among many that have led to the recognition of a major crisis in child protection, not just in the
Northern Territory, but around Australia.

DR HOWARD BATH: This is a problem shared around the country. In fact it's shared in the western
world. Child protection systems are failing.

QUENTIN McDERMOTT: Last month a major report commissioned by the Northern Territory Government was
published pointing to an 'overwhelming failure' in the child protection system, and a 'tsunami of
need' in remote Aboriginal communities.

whole of the child and family welfare sector of the Northern Territory. I was horrified at the need
in the communities and I guess the absence of um, action which in regard to addressing the issues
in communities around children, around families, around um, the, the level of poverty and neglect
in communities.

DR HOWARD BATH: On any metric you use, any statistic, the Aboriginal children in the Northern
Territory are far worse off than any other children, any other population group in Australia and
I'm talking dramatically so.

QUENTIN McDERMOTT: Earlier this year, an inquest into the death of Deborah Melville, a 12 year-old
Aboriginal girl who died in foster care, emphasised how enormous the problem is and how
comprehensively the child protection system has failed.

(To Carolyn Richards, NT Ombudsman): How great was the Department's failure in Deborah's case?

CAROLYN RICHARDS, NT OMBUDSMAN: She died. She died in the most horrific, painful circumstances. So
their failure was complete.

QUENTIN McDERMOTT: As Ombudsman for the Northern Territory, Carolyn Richards is currently
investigating fifty-two cases like Deborah's and the baby boy's, involving children at risk.

Her report, quite separate from the Government's, is expected sometime next year. But already her
verdict is damning.

CAROLYN RICHARDS: I think it would be fair to say that at least 80 per cent, there was an
inadequate response and in 50 per cent, no response at all to what any, any normal person would
consider was a risk prone, terrible, neglectful, harmful situation for any child.

QUENTIN McDERMOTT: Deborah Melville had very young parents.

DARRELL MELVILLE, FATHER: She was a, um, a very beautiful daughter of mine. I was about um, 15, 16
when we had Deborah.

QUENTIN McDERMOTT: Did you have any help in those days?

DARRELL MELVILLE: Um not very much help, it was pretty hard.

FORMER DET. SGT ANNE LADE: It was a volatile relationship in um, there was domestic violence and,
and alcohol issues involved. In 2000 ah, FACS went to court and custody was granted to, to the

(To Darrell Melville): Do you do you think maybe in those days you just weren't responsible enough
to have a kid like Deborah?


QUENTIN McDERMOTT: Wanting to keep Deborah inside the extended family, child protection officers
handed her to a great-aunt, Denise Reynolds, who already had a large family of her own. They did so
without properly investigating the carer's background.

(To Former Det. Sgt Anne Lade): A child of hers had died some years previously while at while under
her care, had drowned?

FORMER DET. SGT ANNE LADE: Yes, one of the great-aunt's own children had died in, in Perth when it
was a youngster.

QUENTIN McDERMOTT: Did FACS know about that?

FORMER DET. SGT ANNE LADE: No, they didn't.

QUENTIN McDERMOTT: Should they have?

FORMER DET. SGT ANNE LADE: I think they, they should have. Ah, ah I think if you're going to put
children into, to someone's care there should be complete background checks on them and things like
that should be known, yes.

QUENTIN McDERMOTT: Deborah Melville was taken to live with her carer's family at an isolated rural
community outside Darwin. Her aunt Colleen Melville saw the conditions they were living in.

COLLEEN MELVILLE: It wasn't a home. It was a shed that was transformed into what they called a

just appalled to think that the Department can place children in this type of environment. The
environment was, to me it was like a cubby house. It was of tin, galvanised tin. There was pots of
tins where the rain came in, that was gathering the rain and just a whole heap of bunk beds.

QUENTIN McDERMOTT: And how crowded was it there?

NATALIE HUNTER: Extremely overcrowded.

From time to time, child protection workers would visit the property, but they never acted to place
Deborah in a better home, despite seeing the conditions she was living in.

CAROLYN RICHARDS: It is just mind-blowing to think that these things were ignored. And I suspect
that the inquiry's right when it says that because this is an Aboriginal family, um, we white
people assume that they tolerate overcrowded um, circumstances that we wouldn't tolerate for white
people. Um, and I'm sure there's an element of that. Um, so...

QUENTIN McDERMOTT: So you're saying there's an element of institutional racism within the

CAROLYN RICHARDS: Acceptance of, yes, acceptance of an inferior standard applicable to um, people
who are Aboriginal.

QUENTIN McDERMOTT: But if conditions here were bad, they became even worse for Deborah when her
great aunt moved the family to a Housing Commission home closer to Darwin.

(To Ricky White): Ricky this is the house where Deborah lived. How many people ah, were living here
at that time?

RICKY WHITE, DEBORAH'S NEIGHBOUR: Um, was Aunty and her kids and stuff, um, there would've been ah,
four at that stage and then the other Aunties and her um, kids moved in and so ah, roughly all up
around about 14, 13.

FORMER DET. SGT ANNE LADE (showing images of the house): This is actually the laundry area but
that's what they used as an entrance, um, to the house. Now we come inside the house and we can see
the kitchen area.

QUENTIN McDERMOTT: Just how crowded the living conditions here were is graphically illustrated by
this video recorded by the police shortly after Deborah's death.

(To Former Det. Sgt. Anne Lade): And it's not very clean is it?

FORMER DET. SGT ANNE LADE: No it's quite dirty. A lot of stuff as you can see, piled up around the
place. The property had the one bathroom and that's the bathroom...

QUENTIN McDERMOTT: So that's the bathroom for 16 people who are living there?


QUENTIN McDERMOTT: Adults shared the cramped living quarters with the children, and one, Colleen's
father who has now passed away, was bailed to live at this address, while on a charge of indecently
assaulting a young woman.

(To Colleen Melville): Should he have been allowed to live there?

COLLEEN MELVILLE: No not, not, not in a household where there's children, no.

(To Former Det. Sgt Anne Lade): Should that have happened?

FORMER DET. SGT ANNE LADE: No, it should not have happened. Um, at the time and I don't know
whether it's changed or not but there was no mechanisms for either police or courts to, to know
where children in care were living, um, so they could bail someone to a house where the children in
care um, were residing and there was no, no way of knowing.

QUENTIN McDERMOTT: On one occasion Colleen says, she found her father and Deborah together in a

COLLEEN MELVILLE: When I walked into the room, I saw my father laying on the bed and he was facing
um, towards the wall and um, I saw, I looked to my side and I saw Deborah sitting inside a
cupboard, um hiding, she was crouching down behind the cupboard um, hiding and I asked her what,
what she was doing in there and she, she, she couldn't answer me. She was really sad and couldn't
answer me and that that gave me the suspicion that something, something was going on.

QUENTIN McDERMOTT: Did you report his behaviour to FACS or to the police?

COLLEEN MELVILLE: I did go and speak to FACS about, about what, what I saw. They said 'look we'll
follow up on it and we'll get back to you.' Where again they, they didn't, didn't hear anything
from them.

QUENTIN McDERMOTT: Between December 2000 and July 2007, Deborah's case workers received multiple
notifications raising serious concerns about the care she was receiving.

This document obtained by Four Corners graphically illustrates what the concerns were about.

In December 2000, when Deborah was six years old, FACS was warned she 'was exhibiting inappropriate
sexualised behaviours'.

Six years later, concerns were voiced that Deborah's home was like a 'concentration camp', and that
'Denise is getting a lot of money but nothing to show for it'.

The truth is that for Deborah's carer, her priorities lay elsewhere.

QUENTIN McDERMOTT: Night after night, Deborah's great-aunt left the children at home, and came here
to Darwin's Casino, to gamble. Deborah's case-workers were told that she had a gambling problem,
but they never investigated the rumours. Each month she received more than $10,000 in benefits.
Most of that went straight into Sky City's pokie machines. Only later did the police establish just
how much she had gambled in a little over four and a half years. It was $1.6 million dollars.

(To Colleen Melville): Did you have any idea that she was gambling heavily?


QUENTIN McDERMOTT: Did you report that?

COLLEEN MELVILLE: I did, I did say that to them, yes.

QUENTIN McDERMOTT: What did they say?

COLLEEN MELVILLE: Again they just said that they'll, they'll have a look into it and speak to her
and get back to me, which they didn't.

FORMER DET. SGT ANNE LADE: I obtained records from the casino here in Darwin and um, it showed that
for a period of about four and a half years prior to Deborah's death um, the carer had been
regularly attending the casino and that she had in fact um, gambled $1.6 million through poker
machines um, during that period.

MURIEL BAMBLETT: I was horrified to hear that. I mean obviously um, if one visited that family
regularly, one would've seen where the actual income was going into. You would've been able to see
if the child was being nurtured. If the child was going to school. If the child was you know having
regular health checks.

QUENTIN McDERMOTT: Had FACS investigated Denise Reynolds' gambling habit, they would have
discovered how often she left Deborah unattended at home.

In the last three weeks of Deborah's life, Denise Reynolds visited the casino sixteen times. Her
constant absences from home allowed an entirely preventable tragedy to unfold. On a school sports
day in June 2007, Deborah reported that she had hurt her leg.

RICKY WHITE: She said she had a sore leg.

QUENTIN McDERMOTT: Did she show you her leg? Was it swollen?

RICKY WHITE: Um, in one area and that was pretty much to her thigh area.

FORMER DET. SGT ANNE LADE: She was got to the point where she couldn't um, ah put weight on her leg
and ah, she couldn't stand up by herself. Um, ah towards the end of the three week period there
were occasions where she couldn't get herself to the toilet and in fact there were a couple of
occasions where she soiled herself sitting on the lounge suite because she couldn't get herself to
the toilet.

DR PETER SHARWOOD, ORTHOPAEDIC SURGEON: She had a condition called osteomyelitis which is infection
in the bone. Osteomyelitis is not a fatal condition when it's treated.

QUENTIN McDERMOTT: Deborah's infection was never treated. On one occasion she was helped over the
road to see her neighbour, Ricky White.

(To Ricky White): What, what did she tell you about the pain?

RICKY WHITE: I just asked her if she was alright and she kind of mumbled and she just wanted to go
back and lie down, so I just said to yeah, take her back home and tell your Aunty to um, take her
to the doctor.

QUENTIN McDERMOTT: But her carer didn't take her to the doctor, and the abscess on her leg grew

The day before Deborah died a new case-worker and a colleague from FACS visited her and her
great-aunt at home. They found Deborah crying in pain on the kitchen floor.

FORMER DET. SGT ANNE LADE: There appeared to be something wrong with her. Um, the carer um, told
the FACS workers that um, she, she would get like that when there was going to be a new case
worker, that she was scared that she'd be taken away and so she'd become upset and, and that's how
the carer explained why she was on the floor and crying. Um, one of the case workers did speak with
Deborah um, and tried to reassure that she wasn't going to be taken away. Um, they did some, had
some discussions with the carer and ah, left the premises.

QUENTIN McDERMOTT: The next morning, Deborah was near death.

Her great-aunt and carer Denise Reynolds had been in the casino until 1.30am, and she made it clear
that she'd lost patience with Deborah, who by now was barely able to move.

FORMER DET. SGT ANNE LADE: She and her son um, took, helped Deborah up and took her outside of the
house and put her on the ground out of the back of the house near a trailer that was out there. The
carer told the other people who at the house, told them that ah, Deborah was to stay out there,
that um, she wasn't to be given any food and drink and if she wanted something she was to get up
and get it herself. Um, and so ah, the carer went off to work, to her job and Deborah stayed
outside um, in the dirt near the trailer for the remainder of the day.

QUENTIN McDERMOTT: Deborah lay outside all day, delirious and dehydrated, as family members moved
in and out, around her.

DR PETER SHARWOOD: She would have been in extreme pain and extremely ah, absolute extremis, very,
very quickly in those circumstances.

QUENTIN McDERMOTT: In the late afternoon, eyewitnesses would later report, Deborah screamed out for
a light to be put on.

Shortly afterwards, she died.

CAROLYN RICHARDS: They didn't assess the circumstances under which she was living. They didn't
properly assess the care giver who was looking after her. They didn't visit every couple of months,
um, they didn't see her alone. They didn't respond to reports from neighbours and then when they
visited her the day before she died, they didn't recognise that here was a girl in severe pain with
nearly a litre of pus in her leg, she was incontinent, like one look at her must have told them
this child is not well.

QUENTIN McDERMOTT: Following her death, Deborah's carer Denise Reynolds stood trial for Deborah's
manslaughter, but was acquitted.

Deborah's legacy has been to shine a light on the failings of the child protection system, and the
failure of senior bureaucrats and politicians to recognise the scale of the problem, and fix it.

JODEEN CARNEY, FMR OPPOSITION LEADER, NT: I think there has been high levels of ah, bureaucratic
and political incompetence. Indeed I would go one step further. Ah, I would say there's been high
level negligence. Ah, I don't think it's too much for Territorians to ask that those in the
position ah, to make a difference should make a difference. Those in the positions of power should
be able to exercise that power satisfactorily. Ah, clearly on any analysis they have failed.

PAUL HENDERSON: CHIEF MINISTER, NT: The system has failed because it has been the wrong system. Ah,
the system has really been ah a top down approach and what we need now is to invest in communities,
invest in strengthening families, strengthening communities, particularly remote communities in the
Northern Territory and rebuild this system from the bottom up.

QUENTIN McDERMOTT: Inquiries into Deborah's death and the child protection system have opened up a
Pandora's Box of reports of children at risk, which have either not been investigated, or worse,
just written off.

More than 800 such notifications are still awaiting investigation.

DR HOWARD BATH: In an overwhelmed system you cut corners and when you cut corners, you cut corners
in all areas. Ah, one of those areas is in investigations and we're talking about not actually
undertaking investigations according to both um, you know the, the guidelines, ah and the accepted
best practice around Australia.

PAUL HENDERSON: What I will absolutely recognise is the caseloads for those workers were crushing,
were crushing and that's why we absolutely have to put more people into the system and ah, when
people are under pressure and I don't apportion any blame here, when people are under pressure,
then of course people cut corners. So we have to rebuild the system.

QUENTIN McDERMOTT: But rebuilding the system will be a long and arduous task. And until that
happens, it's doctors and nurses in hospitals who pick up the pieces when the child protection
system fails.

Susan Mansfield used to be a social worker at Royal Darwin Hospital and is still employed within
the Department of Health.

She and other colleagues say they were intensely frustrated by the failure of child protection
workers to follow up and investigate their notifications of children at risk.

SUSAN MANSFIELD: Quite often I'd be told that 'no it doesn't fit the criteria'.

QUENTIN McDERMOTT: In one particularly horrific case, a mother gave birth to a child but later
died, after contracting swine flu.

The baby boy and the mother's two other sons were handed over to an uncle, but not before Northern
Territory Families and Children was told repeatedly, that the baby was at risk.

SUSAN MANSFIELD: I did four written notifications but also had several telephone conversations um,
with ah, NTFC workers um, who consistently refused to become engaged in the case. Um and to this
day I don't understand their reasoning why they declined to, to become involved.

QUENTIN McDERMOTT: Three weeks after being given to his new carer, the baby boy was readmitted to

SUSAN MANSFIELD: The baby was brought into the emergency department with bilateral bleed to the
brain and um, broken bones. I wasn't actually working in emergency department at the time so I, it
was all um information that was passed on to me second hand.

QUENTIN McDERMOTT: How did you react when you...


QUENTIN McDERMOTT: ...learned what had happened to the baby?

SUSAN MANSFIELD: I felt like I'd let him down because he was perfectly healthy up until he was
discharged and he, he was gorgeous. Um, he had um, he had hope and a future and I don't know what
his future involves now.

DR TERENCE DONALD: He had a, a head injury which eh, had all the features of being inflicted. It
was a suspicious head injury. It was a high-force head injury and there was no, from our
perspective, no adequate explanation to account for that.

CAROLYN RICHARDS: That baby boy has got long term permanent um, disabilities arising from an injury
to the brain and it was predictable.

QUENTIN McDERMOTT: Following this terrible event, Susan Mansfield raised the matter with the
Children's Commissioner, Howard Bath.

SUSAN MANSFIELD: Obviously I had the history of the many notifications that I'd made beforehand
with other children and I was becoming increasingly frustrated over the Department's lack of
response and, and so when this happened it was to me like the straw that broke the camel's back,
and I felt that you know, who was going to be the voice for this child, that it did need to be

QUENTIN McDERMOTT: Dr Bath carried out an investigation and told Susan Mansfield, "The essence of
your complaint is substantiated. It's our opinion that the Department should have acted to protect
this child."

He thanked her "for your commitment and perseverance in this tragic case."

But after taking her complaint to the Children's Commissioner, Susan Mansfield says she was
threatened with disciplinary action by a senior departmental officer.

SUSAN MANSFIELD: That particular person became very angry once she learnt that I had spoken to the
Children's Commissioner. Um, I felt intimidated and um, extremely uncomfortable. I felt like I had
done the wrong thing.

CAROLYN RICHARDS: People like Susan Mansfield and others who don't wish to be named, have shown
great courage after a long time of standing back and being demoralised, not getting any support
from the management level immediately above them and in Susan's case, actively being subjected to
reprisals after she spoke out.

QUENTIN McDERMOTT: When a health professional raised her concerns about the case with the
Children's Commissioner, she was castigated for doing so by a superior. That's unacceptable isn't

PAUL HENDERSON: Absolutely, totally unacceptable. Children have to come first.

JODEEN CARNEY: It is shameful that government just let it happen and let it happen and let it
happen and now once again, the Territory is in the national spotlight ah, for the way that ah,
government ah, treats children in the Territory.

QUENTIN McDERMOTT: The task for the government and for the Territory's communities now is to ensure
that children do come first. And that tragedies like Deborah's and the baby boy's, never happen

(To Paul Henderson): What guarantee can you give that there won't be more deaths, that there won't
be more tragedies like Deborah's?

PAUL HENDERSON: Well Quentin you know, I would hope and pray that that would never happen again.
You know, that was just such a tragedy that just reached into the heart of every person that read
about that case. Now I'm determined that that will never happen again.

(To Howard Bath): Can the government solve this on its own?

HOWARD BATH: Absolutely not. Um, one of the messages from all around the country is that looking
after children, protecting children, supporting families is everyone's business.

QUENTIN McDERMOTT: Early next year meanwhile, the mother of the baby boy who starved to death will
be eligible to apply for parole.

(To Son): What are her plans when she gets back into the community?

SON: I don't know, I'm not, the gaol don't allow much contact between me and my mum so...

QUENTIN McDERMOTT: Would she like to get her kids back?

SON: From knowing my mother, not from her saying this, she definitely will be trying to get her
kids back.