What recent Coronial Inquests tell us about the importance of Safeguarding

On 21 October 2022, the Coroner’s Court in Lidcombe NSW handed down its findings into the Inquest of Rachel Ann Martin (Rachel) and Riley Christopher Shortland (Riley)

The devastating events of 5 November 2017, which led to the death of both Rachel and Riley, could have been prevented. The Coroner’s Court made findings and recommendations in relation to Rachel and Riley’s deaths, and we strongly urge Disability Service Providers, respite agencies and other organisations working with Children and vulnerable people, to implement the recommendations.


Riley was 8 years of age at the time of his death. Riley was diagnosed with Autism Spectrum Disorder and Global Development Delay and received funding for his disability under the NDIS. Riley was subject to Children’s Court orders providing parental responsibility to the Minister for Communities and Justice (Minister) and resided in a residential foster care placement. At the time of Riley’s death, he was in a respite placement supervised by provider SNAP.

Rachel was a 28 year old employee of SNAP who was providing care for Riley on 5 November 2017. Rachel was pregnant at the time of her death and was described by her employer as a skilled and dedicated worker.

On 5 November 2017, when Rachel was transporting Riley by car on the M1 Motorway from his respite placement to his foster care placement, the tragic incident unfolded. The Coroner found that it is likely that on the journey, Riley had removed his car restraint and climbed from the front seat into the back seat, which caused Rachel to pull over into the emergency lane on the Motorway. When the car was stationary, Riley opened the car door and escaped from the car onto the Motorway. Without hesitation, Rachel engaged in the heroic act of attempting to chase after Riley, in an attempt to save Riley’s life.

Both Rachel and Riley were tragically killed by an oncoming vehicle.

Findings of the Inquest

The Coroner found that Riley was known to abscond and remove his seatbelt, and additional safety measures were required in order to keep Riley and carers safe. It was well known to the Department that ‘traffic, roads and travelling’ were identified as extreme risks for Riley, and Riley’s Behavioural Support Plan (BSP) indicated that Riley had a targeted behaviour of ‘getting out of his car seat whilst travelling in the vehicle’. Due to Riley’s Global Development Delay, he did not understand societal issues such as safety, and multiple documents stated that a prescribed restraint should be used at all times when transporting Riley in a car. Additional documents attached to Riley’s BSP stated that Riley must have a carer seated next to him when driving in a vehicle, and the vehicle must be parked in a safe location before attempting to strap him back in his car seat.

The Coroner found that the provision of a respite placement with SNAP was ‘rushed, and no proper assessment of Riley’s needs was made in that process and consequently it was not adequately child-focused’. In the haste to organise a respite placement for Riley, vital information had not been provided by the Department, or sought by SNAP, in relation to Riley’s behaviours and needs including his BSP. The Coroner made a number of findings in relation to both DCJ and SNAP failing to adequately share and seek information, to ensure the proper care of Riley.


The Coroner made a number of recommendations, in addition to the commentary around information sharing as detailed above, including that SNAP should:

  1. Develop staffing policies addressing the amount of hours an employee may work;

  2. Seek an independent third party adviser to review any relevant regulations and new policies and implement training;

  3. Develop a policy in relation to staff escalating concerns independently of management and the senior executive team;

  4. Implement Professional Assault Response Training (PART); and

  5. Update its transport policy to include additional safeguards for transporting children in their care

In addition, a number of recommendations were made to the DCJ and Ombudsman which impact directly on agencies providing care for children especially in relation to transport and risk assessment.

What do these Inquests tell us about the importance of Safeguarding?

Organisations working with children owe a duty to take reasonable care to protect children and young people from a reasonably foreseeable risk of harm.

When organisations take on the care and responsibility of a child or vulnerable person, they must be aware of the risks to that individual child or person and take steps to mitigate that risk.

The Inquest is a strong reminder, that risk cannot be assumed and that up to date information must be provided and sought when adopting responsibility for the care of children and vulnerable people. This is especially important for children and people with a disability as they are even more vulnerable to the risk of harm due to their diagnoses and dependence on carers.


In light of the findings and recommendations of these heart wrenching Coronial Inquests, we encourage organisations to review their policies and procedures, and their implementation, in relation to information sharing, transport, staff policies and training.

How can Safe Space Legal help?

Safe Space Legal provides expert advice in child safety and safeguarding and can assist organisations in policy review and drafting, audits and gap analysis, investigations and desk top reviews, training and legal advice in safeguarding including the Child Safe Standards and relevant reportable conduct and incident management schemes.


We welcome you to contact Safe Space Legal to discuss your organisation’s safeguarding needs.

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