Overview

• The coroner concludes youth protection, the health network and the school system failed to coordinate an effective response to protect the seven-year-old.
• The report details that the child died in 2019 from external suffocation after being found with adhesive tape obstructing her airways.
• Numerous consistent warning signs were identified over years of contact with professionals, with the coroner asking why placement with a third party was not pursued.
• Twelve recommendations call for stronger information‑sharing, clearer roles across departments and decisions that prioritize the child's needs.
• The case previously led to a public inquiry and prosecutions; the stepmother is serving life for second‑degree murder and the father pleaded guilty to a reduced unlawful confinement charge and was sentenced in 2022.