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NSW Coroner addresses shortcomings for organisations after Murray River child drowning

Victorian Emergency services personnel search at Moama on Friday, Mar. 3, 2017

A coroner has made 17 recommendations following the drowning death of a five-year-old boy in the Murray River due to acts by his mentally ill mother.

The mother was found not guilty of murder in the NSW Supreme Court by way of mental illness based on unanimous expert evidence in 2017. 

An inquest in Deniliquin in May 2021 examined 28 key issues focusing on the organisations and agencies the mother was involved in, and potential shortcomings and inadequacies. 

Coroner Teresa O'Sullivan in Lidcombe Coroners Court on Friday said the child was clearly a much-loved younger brother and adored by his grandparents:

"He was described as full of life from an early age, loved to play games and attend the local park ... very outgoing and always carried a toy truck or ball."

She concluded that the child died at about 6.15pm on March 2, 2017 due to the acts of his mother, and made 17 recommendations - key among which was that the tragedy be considered a 'case study' on the need for a 'cumulative and holistic approach to information held by agencies' and:

  • An alert in the apprehended violence order (AVO) application system to police officers of their obligations regarding domestic and personal violence 

  • Review domestic violence procedures and associated training to ensure the significance of listing a child as a person in need of protection is well understood

  • Reports concerning the welfare of missing persons to include prompt risk assessment that includes mental health and other histories

Among the agency-specific recommendations:


  • Consideration of missing persons policy when a child is removed from their usual residence without consent of carer

  • Cautious approach where police are called to conduct a welfare check on vulnerable persons and associated training


  • Training that targets situations where a child is removed from their usual carer, and the significance of an AVO naming a child as a person in need of protection in the event they are taken away


  • Prepare a written protocol about the transfer of information between Corrective Services NSW and MLHD upon a person's release from custody


  • Review its child protection policy to consider reporting a matter to NSW police as well.

The mother, 27, had taken her two sons aged five and nine to the Murray River at Moama west of Albury, and across the border from Echuca in Victoria.

The undisputed evidence at her Supreme Court trial was that she caused the death of her youngest son by holding his head underwater and drowning him.

According to the judgment, she made a concerted effort to do the same to her older son but he managed to escape.

In closing the inquest the coroner offered her sincere condolences to the late child's family, saying his grandmother displayed enormous dignity, courage and strength in giving evidence. 

Those distressed by this story or needing support can contact Lifeline on 13 11 14 – 24 hours a day, 7 days a week or Beyond Blue: 1300 22 4636 - www.beyondblue.org.au