The parents of a toddler who drowned while in foster care say the NSW child protection system "stinks" and change must be made to prevent further deaths after the handing down of the coroner's findings at the inquest into their son's death.
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Vanessa Naumovska and Johnny Slager broke down as they remembered their son, Braxton Slager, who was found floating in the swimming pool by his foster mother in 2014.
"The whole system stinks, something needs to be done about it for the little kids that are still in care now," Johnny Slager said outside the Glebe Coroners Court on Tuesday.
"My kid is gone and I spew about that. I really love him and I miss him so bad but he's gone."
The 22-month-old died in September 2014, three weeks after he was placed with a western Sydney family by a government-contracted, out-of-home care provider.
Deputy State Coroner Harriet Grahame said Braxton's case highlighted "systematic problems".
"The failings strike at the heart of the way we care for the most vulnerable children in this community," she said in her findings.
"Tragically the ongoing inadequacy of resources allocated to the care system in general is once again demonstrated in a matter coming before this court and I once again urge governmental review of this issue."
Ms Grahame said Braxton should not have been placed in the care of Julie Tarlinton and Greg McBride, who were already looking after two other foster children when he arrived in August 2014.
One of them, a nine-year-old boy, suffered intellectual disability, while the home was unsafe.
The coroner found the couple's pool was unregistered with the local council, failed to comply with safety standards and was effectively unfenced - something Life Without Barriers, the provider contracted by the Department of Family and Community Services, should have spotted, she said.
The presence of the antihistamine Cyproheptadine in Braxton's blood following the autopsy was also "extremely troubling".
If the drug was taken accidentally it indicated poor supervision, but if was given to the child in an attempt to make him sleep or quieten down, it was even more serious, she said.
Ms Grahame said Life Without Barriers' process for choosing suitable foster carers and providing support to carers had failed.
The agency had not completed a formal check of Ms Tarlinton's and Mr McBride's home since September 5, 2012.
"Tragically, a child who went into care to improve his chance of living in a safe environment, found himself in a situation of enormous risk," she said.
"His death appears to have been a preventable accident, which occurred against a background of inadequate care."
The coroner was also critical of FACS' handling of Braxton's parents.
She said Mr Slager was coerced into the temporary care agreement, while Ms Naumovska did not give her consent at all.
There are around 18,000 children and young people in out-of-home care in NSW.
NSW Minister for Family and Community Services Pru Goward said FACS and its partners need to continuously review their practices.
"The government will consider the Coroner's findings. If there is more that needs to be done we will do it," Ms Goward said.
Australian Associated Press
