Queensland's child safety department's handling of toddler Mason Jet Lee's case was a failure in nearly every way, a coroner says.
The 22-month-year-old died after he was struck in the abdomen by his mother's boyfriend so hard it ruptured his small intestine, which led to an infection in June 2016.
"I conclude that the department failed in its duty to protect Mason from the risk of serious harm that he faced in the months prior to his death," deputy state coroner Jane Bentley said in her inquest findings today.
"The errors and failings of the individual employees of the department were merely the component parts of the collective failure of the department."
Ms Bentley told the Brisbane Coroners Court her findings contained graphic and distressing details about Mason's life and last days.
"I include it in the findings not to shock or upset but in recognition of the fact that these things happened to this little boy whilst he was a child in our community," she said.
"If Mason had to endure these things then we as a community should be aware and acknowledge them."
An autopsy conducted on Mason found his death was caused by the infection, but that he had numerous other injuries indicating he had been severely mistreated for some time.
He had been punched or kicked with such force that it fractured his coccyx several days before he died.
The toddler also had illicit drugs in his system.
The findings outlined how the little boy's declining health in his final days had been largely ignored by his mother and stepfather, who are both serving jail sentences for his manslaughter.
Attempts by neighbours and friends to get them to seek medical help for him were unsuccessful.
The family had been known to the child safety department since before Mason's birth in 2014.
In 2015 the department found the children were safe with their mother and did not need to be fostered out, despite evidence she had been using drugs and alcohol.
Mason was hospitalised in early 2016 when a doctor noted the worst injuries he had ever seen.
The department again made the decision to release the toddler back to his family.
The last time anyone from the department actually saw Mason was in March 2016.
Ms Bentley's assessment of how the department handled the case was damning.
"Despite all of the information available to the department, which clearly indicated that Mason was a child at risk of serious harm, nobody from the department saw him or checked on his welfare for three months before he was killed," she wrote.
She acknowledged the department was understaffed and staff were overworked.
However, she said the case was mismanaged on a number of levels, and that the department needed to review its policies about how it implements out-of-home care for at-risk children.
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