Dr Heath reports that acute subdural haemorrhages usually develop after high speed acceleration / deceleration injuries and can result in death by causing an increase in intracranial pressure which in turn can cause compression and damage to underlying brain tissue. In this case the mechanism of the lethal injury would have been the combined effects of direct trauma to the brain from blunt force impact resulting in multiple skull fractures with a depressed skull fracture in addition to severe acceleration / deceleration injuries due to impact of the head with a hard object resulting in bilateral subdural haemorrhages which would have caused death through raised intracranial pressure. I accept all of that evidence and find that Ebony’s blunt head trauma resulted from multiple blows to the head by, or against, a hard object or surface. In addition to the head injuries, there were multiple additional bony injuries to other parts of Ebony’s skeleton including the spine, rib cage and upper and lower limbs. These injuries were revealed either from the anatomical findings at autopsy or from the skeletal survey and full body CT scan, or all of those modalities. The number of bony injuries was extraordinary. There were forty-eight old healing rib fractures alone. There were four recent rib fractures. There were two possible crush fractures to thoracic vertebrae. There were bony injuries to the upper limbs as well as to the feet. The fractures were of differing ages. Post-mortem radiological appearances suggested the presence of more recent fractures occurring through older fractures. In particular many of the rib fractures, as well as a fracture to the right clavical and fracture of the right humerus, showed changes suggestive of new fractures occurring through sites of healing older fractures. There was evidence of a healing fracture through the midshaft of the left femur (left thigh bone) which I will return to in a moment. As to the mechanism of the fractures, Dr report suggests that the rib fractures were consistent with a compressive or squeezing force such as that provided by encirclement by hands. Finger and toe fractures were consistent with squeezing or stomping on the hands or feet. In this case the fractures observed are described by Dr Heath as being highly specific for inflicted injury, that is to say, deliberately inflicted injury and distinct from the accidental. I have accepted Dr Heath’s evidence in its entirety.
Australian interstate liaison officer (ILO) and NSW DoCS officers regarding C’s status and other matters affecting her but not directly related to Ebony. from a verbal request, a request for information from SA to NSW could also more formally have been effected by way of the completion of a straightforward form specifically designed for the very purpose. The failure of the South Australian authorities to inform itself about Bradley history was a serious oversight and I have little doubt that proper inquiry in respect of this topic could have been enough to have prevented Ebony’s death. It could and should have altered what ultimately became a casual approach to her protection on the part of Families SA. Events following the first notification to Families SA In this section I will discuss events during the period from Ebony’s discharge from hospital following her birth until her hospitalisation on 10 August 2011. During that period Ebony was the subject of the notification that had been made to Families SA by the WCH social worker on 6 July 2011. was discharged from the WCH on 8 July 2011 following her birth on 4 July 2011. She was discharged into the care of her parents. The family resided in the unit at Brooklyn Park to which I have already referred. Although Ebony was the subject of the notification to Families SA, she would not actually be sighted by a Families SA employee until 1 August 2011. Even then, there is good reason to believe that the home visit that was conducted by the Families SA employee only took place as the result of further concerns raised by staff employed by the CAFHS. Any detailed analysis of what transpired between 8 July 2011 and 10 August 2011, as with all aspects of this matter, has to be examined against the premise that any engagement between Ebony’s parents and any service provider, including Families SA, was fundamentally flawed as a result of the fact that none of these services knew of the background or history of Bradley Napier-Tucker. This is no criticism of service providers such as CAFHS because no-one from that entity was in a position to have obtained the information about Bradley Napier-Tucker that needed to be obtained.
names he called her. Both Mr and Mrs Grenci speak of Bradley Napier-Tucker’s aggressive reaction to their enquiry as to whether the family was receiving assistance through CAFHS or Families SA. Napier-Tucker had said that he did not want that type of intervention because the authorities had caused his son to be taken away from him, which in hindsight is a clear reference to the child M. Mrs Grenci had to tell him to calm down. All of this evidence tends to confirm that concerns entertained within CYWHS had not been misplaced. As events were to transpire, Mr and Mrs Grenci would likely be the last persons to see Ebony alive. This occurred on Sunday 16 October 2011, approximately three weeks before Ebony’s death. Mr and Mrs Grenci on the one hand and Napier-Tucker and C on the had been perfect strangers before they met in early 2011. It is apparent from the statements of Mr and Mrs Grenci that there was a strong element of compassion in their interest in Napier-Tucker and C having regard to the strained circumstances in which the young couple had found themselves once in South Australia. Mr and Mrs Grenci endeavoured to provide significant support for this family for which they are to be commended. It is obvious that they took a genuine and compassionate interest in C and Bradley Napier-Tucker, and Ebony after her birth. Ebony is admitted to hospital with a broken femur I have already mentioned Ebony’s broken femur. It was the sole injury that was indentified during her life. It constituted a circumstance that ought to have seen Ebony removed from her parents. Mr Keane of counsel for the Minister for Education and Child Development, for the Minister for Health, for the Women's and Children's Health Network and for Dr Terrence Donald, the then head of the Women’s and Children’s Hospital Child Protection Services (CPS), candidly told the Court that his clients accept that the investigation into this injury as carried out by the Child Protection Services miscarried. I agree and so find. In my view the evidence demonstrates that the investigation was a truncated and ill-informed affair that lacked proper cohesion and which wholly failed to protect Ebony. It is also important to note that the investigation was carried out in the absence of any knowledge of Bradley Napier-Tucker’s background or propensities and so to that extent it was flawed from the outset. But even allowing for the absence of that information, the manner in