A national database for child protection cases has been recommended after an inquest into the death of baby Ebony.

South Australia’s Deputy Coroner Anthony Schapel said baby Ebony’s death could have been prevented if Families SA and South Australia Police had better handled the case.

Ebony was left lifeless in her cot for at least a week at her young parent’s Brooklyn Park unit in Adelaide’s west before they alerted Families SA.

In sharing his findings, Mr Schapel said that Families SA should have taken a keener interest in the girl’s care and ongoing protection.  Families SA was originally alerted to the baby girl after her leg was broken, prior to her death.  However a thorough police investigation was not conducted.

Mr Schapel said Families SA had investigated the broken leg bone with a “lack of enthusiasm”.

The inquest heard evidence that the teenage parents had moved from New South Wales when the mother was pregnant and the mother was under the guardianship of the NSW Government.

Mr Schapel said his recommendation for a national child protection database would ensure immediate access to interstate records.

He also added within his recommendations that the process of sending out an alert when contact is lost with a child’s parents was a necessary and important part of ensuring the safety of a child.

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  • There needs to be more in place yes to protect and monitor so this will never happen again. But when it comes to light don’t just let it build it needs to be looked at straight up.


  • This sounds very sensible and begs the question why does it take a tragedy to get the ball moving


  • Lke mk


  • This is very important. I can’t believe there isn’t one


  • It would help to have such a database. All the various agencies (hospitals, police, Families SA etc) can then be able to access information about suspicious cases which presents.


  • A very common sense approach. I can’t understand why it takes a tragedy to implement change.


  • i’m suprised that there wasn’t already some kind of database!


  • This is common sense. I’m surprised it’s taken so long to recommend these changes, let alone implement them.


  • I agree. It looks like a very important step to take!


  • That’s a long overdue initiative. I hope it happens soon.


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