Deaths of Children in Out-of-Home-Care: What do Inquest Reports Reveal About the Framing of Child Protection Practice?

In Western Australia (WA), a coronial inquest into the death of a child who had been in care is mandatory. An inquest is a public hearing, a fact-finding process to determine the cause of the death, prevent future deaths from occurring in similar circumstances and to comment on the public health implications. With these functions in mind, an analysis of the inquest reports regarding the deaths of children aged 13–18 years who were in care was undertaken. The aims were to make visible the representations and frames that describe child protection practice in relation to these children who were in out of home care, the complex problems faced by their families and the care and support provided to them by the child welfare system. We identified three frames: blame featuring individual responsibility and parental deficits, disengagement and service delivery failure as a missed opportunity. We conclude that what is needed in coronial inquests is a fuller representation of broader systemic issues that are inevitably consequential for child and family well-being. Highlighting social and structural inequalities, trauma, discrimination and racism could arguably maximise the potential for coronial findings to reflect the need for supportive practice and a more preventative approach.