THE tragic death of a North Queensland toddler while in the care of a 74-year-old foster mum should be used as a "case study" in the training of carers to prevent similar deaths, according to the coroner.
Cairns Coroner Kevin Priestly this week ruled two-year-old Luke Anthony Borusiewicz died from a severe head injury he received after striking his head while jumping on a bed as his elderly foster mother slept nearby in January 2009.
Mr Priestly, in his 18-page decision, said the toddler received the injury when he fell and banged his head against the bed frame and floor next to his sick and fatigued carer and another young foster child.
The inquest was told when the woman, identifiable only as Joy, awoke she believed Luke was asleep, but when she could not wake him a short time later, she called for an ambulance.
Luke died as a result of his injuries in the Cairns Base Hospital six days later.
In 2008, Luke was the subject of a Child Protection Order and placed in Joy's care.
Mr Priestly found there was no evidence the suggest that Joy or child protection or support agencies, including Child Safety Services, had failed to discharge their "responsibilities in managing the care and protection of Luke".
However, Mr Priestly did recommend Luke's case be used as a training guide to alert prospective carers and agency staff about the "insidious dangers'' of fatigue when caring for children.
The inquest was told Joy was feeling unwell and very fatigued on the day of Luke's fall.
"Joy had an ‘upset stomach’ that was limiting how much she could eat and drink ... (and) she had four fostered children in her care including Luke,'' he said.
"At about 11.15am, Luke had settled in his bedroom in the company of the 9-year-old foster child (and) Joy laid down on her bed for a rest. She fell asleep and slept.''
"(Luke's) fall occurred while Joy was sleep.''
Mr Priestly on Tuesday found Joy's fatigue, along with the limited consumption of food and water, reduced her ability to assess her "level of tiredness".
"The circumstances surrounding Luke’s death should be used as a case study in the training of foster carers in self awareness and the insidious nature of fatigue,'' she said.
"(It could also be used) training of Placement Support Works and Child Safety Service officers in the need for vigilance in monitoring foster care arrangements."
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