A NSW coroner says the case of an unsupervised toddler’s drowning in an unregistered backyard pool while in foster care pointed to systemic problems.

March 27, 2018

A toddler’s drowning in a backyard pool while in foster care was a terrible but preventable tragedy, a NSW coroner has found.

The 22-month-old died in September 2014, just three weeks after he was placed with a western Sydney family by a government-contracted out-of-home care provider.

Deputy State Coroner Harriet Grahame told Glebe Coroners Court on Tuesday Braxton Slager’s case highlighted “systematic problems”.

“The failings strike at the heart of the way we care for the most vulnerable children in this community,” she said in her findings.

“Tragically the ongoing inadequacy of resources allocated to the care system in general is once again demonstrated in a matter coming before this court and I once again urge governmental review of this issue.”

Ms Grahame said Braxton should not have been placed in the care of Julie Tarlinton and Greg McBride, who were already looking after two other foster children when he arrived in August 2014.

One of them, a nine-year-old boy, suffered intellectual disability and various disorders, including autism.

The foster parents’ home was unsafe.

The coroner found the couple’s pool was unregistered with the local council and failed to comply with Australian safety standards – something Life Without Barriers, the provider contracted by the Department of Family and Community Services, should have spotted, she said.

The presence of the antihistamine Cyproheptadine in Braxton’s blood following the autopsy was also “extremely troubling”.

If the drug was taken accidentally it indicated poor supervision, but if was given to the child in an attempt to make him sleep or quieten down, it was even more serious, she said.

Ms Grahame said Life Without Barriers’ process for choosing suitable foster carers and providing support to carers had failed.

“Tragically, a child who went into care to improve his chance of living in a safe environment, found himself in a situation of enormous risk,” she said.

“His death appears to have been a preventable accident, which occurred against a background of inadequate care.”

Braxton’s father Johnny Slager said outside court the NSW child protection system “stinks” and changes need to be made for children now in care.