Lessons not learnt are doomed to be repeated: The case of BS, a death in out of home care

Dr Karen Fisher1, Judith  Fraser

1Drug And Alcohol Service, NBMLHD, Kingswood, Australia

The issues of out of home care are complex, with recent Royal Commissions, reviews and scholarship suggesting far more consideration and caution be given to decisions to place children such forms of care.  When a placement ends catastrophically, in either death or significant harm to a child, the agency or governmental bodies who organised the placement are typically investigated, systems issues detailed and reforms inevitably follow. A  recent case reviewed by the NSW Coroner,  illustrates there is not the same level of scrutiny and interrogation of the “evidence” and “reporting” by health service clinicians used by governmental departments to inform their decisions on the level of intervention thereafter undertaken. This presentation will suggest the evidence from a medical file, cannot simply be assumed irrefutable. By analysing the creation of the medical narrative, the various often competing, philosophical frameworks used, the discordant voices captured and the perils of collapsing the information in a file into knowledge of a child’s life in a family,  the failure of health to learn from its own history  and mistakes, will be made apparent.

Using the case of BS, it will be argued the Coroner was not allowed the opportunity to consider the role and responsibilities of the health service who made the assessment leading to the brief removal of BS from his fathers care.  By adding the upstream events in this tragic case,  more can be learnt and a far more nuanced understanding of how health can cause irrevocable harms even as it seeks to adhere to its first principle of avoiding such  harm at all costs.  How can this case illustrate a way forward in deciding just what “evidence” means in a clinical file?


Dr Fisher is Clinical Director of Drug and Alcohol Services at NBMLHD. She is an active and committed teacher and clinician, whose interests include stigma, public health, Addiction Medicine and bioethics

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