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Coroner finds drugged toddler’s drowning in illegal pool was preventable

April 11, 2018

The 2014 drowning death of 22-month old toddler Braxton Slager at Stanhope Gardens, NSW, was the result of several instances of poor supervision not only by the foster parents but also by the care organisation, and poor decisions by the Department of Family and Community Services (FACS).

The deputy coroner, Magistrate Harriet Grahame, found Braxton’s death was preventable.

Police who attended the scene described the house as “messy and untidy” and the backyard as “messy, dangerous to children and similar to a dumping ground”. In particular, it was noted that the backyard contained multiple items, such as discarded building materials, tools, nails, metal objects, alcohol and beer cans. Paramedics described the property as “untidy and unkempt” and “messy and dark”.

Swimming pool unsafe

The water in the pool was green and appeared not to have been maintained or cleaned in a long time.

The swimming pool in which Braxton drowned was unregistered and had never received approval from Blacktown City Council. The pool was installed in October 2012 for the use of a previous foster child. Installation was completed just a few weeks after the home environment checklist was carried out on 5 September 2012.

Neither the pool nor the enclosing fences complied with the Australian Standard.

The carer organisation Life Without Barriers (LWB), which is a contracted foster care contractor to FACS, prepared a safety check of the housing in 2013 and 2014 but neither included evidence of the pool. However, other staff members were aware of the pool’s existence but had not directly informed the other officers or their managers until after Braxton’s drowning.

LWB has accepted that the organisation had some systemic failings which needed to be urgently addressed at a policy level. The kinds of changes identified fall into two broad categories, firstly changes in relation to placement practices and secondly changes in relation to home environmental safety checks.

The deputy coroner also said the push for a temporary care order by FACS was in her view both ill-conceived and poorly executed.

Presence of allergy drug

Toxicological testing of Braxton’s post-mortem blood found the presence of an allergy treatment drug, used by one of the foster parents and normally kept out of reach. The medication was not recommended for use in children under the age of two and its use could lead to sedation, dizziness, reduced co-ordination and confusion, as well as restlessness and excitation.

In finding Braxton’s death preventable, the deputy coroner said that first, he should not have been placed with the foster parents in question, the premises provided should have been safe, and the presence of cyproheptadine in Braxton’s blood is also extremely troubling. At best, if it were ingested accidently, it indicates a serious lack of supervision and drug control. If given to him by one of his carers or someone else in that house, in an attempt to make him sleep or quieten him down, it is clearly even more serious and indicates a complete lack of suitability to be involved in out of home care by the person or persons involved. However she could not make a final conclusion on that issue.

The swimming pool has since been removed from the residence.


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