The sentencing judge, Justice Elizabeth Fullerton, was satisfied Khazma derived “some perverse pleasure” from the child’s pain. She jailed Khazma for 44 years, with a non-parole period of 33 years.

DB’s mother pleaded guilty to manslaughter on the basis that she failed to protect her daughter. She was jailed for three years with a non-parole period of 16 months.

Missed opportunities and failures

The inquest focused on whether the agencies involved, including the NSW Department of Communities and Justice (DCJ), could have done more to prevent the circumstances in which DB’s death occurred.

“The court was keen to understand why she was not visible to people who could have assisted her,” the coroner said.

The inquest heard DB’s family became involved with the department in May 2015 following a Risk of Significant Harm (ROSH) report by an anonymous female caller. The family was referred to the intervention program Brighter Futures, run by not-for-profit organisation The Benevolent Society.

‘[The child] had been struck, burnt and bitten... The pain she had suffered must have been unbearable.’

Harriet Grahame, deputy state coroner

The coroner accepted the referral was “premature”, had a “devastating flow-on effect”, and was a missed opportunity for a more formal departmental response.

Over three months, seven ROSH calls were made to the DCJ Helpline about DB and her brother, raising serious concerns about the mother’s behaviour, including abuse and neglect.

“Some of the reports recorded that the children were coming into contact with people who may be dangerous,” the coroner said.

However, a DCJ caseworker wrongly characterised the reports as “malicious” or “vexatious” after DB’s mother claimed they were being made by a former friend. That worker was unaware they were from five different women.

The seventh call was made in August 2015 by a caseworker for The Benevolent Society after the family had moved to another DCJ district. The worker raised concerns that the mother would not seek medical assistance for any injury to her daughter, and said “future concerns may go unnoticed given the family has moved, and Brighter Futures would not be working with [the mother]”.

The coroner said that report, in hindsight, was “chilling” and “should have prompted immediate action” by DCJ.

But the family’s file did not follow them to their new location, so there was no further risk assessment, and the department ultimately closed the case.

“No adequate reason has been given for this major failing,” the coroner said. “The movement between districts is irrelevant to the concerns raised. I consider this a very significant failure.”

‘We loved each other very much. We would run through the hallway and meet in the middle to hug each other and laugh.’

The brother of the murdered toddler

The inquest heard there was no record of any contact between DCJ and the family, or any further Helpline call or report, between August 2015 and December 2016 when DB died.

The coroner characterised the file closure, on the information at the time, as “inappropriate” and “unsafe”.

She commended The Benevolent Society workers who had “tried to trigger DCJ to consider a statutory response”.

“I regret the trauma they have suffered in later learning what happened to the children after DCJ closed its file,” Grahame said.

‘Urgent’ need for major reform

The coroner said there was no suggestion that the “very specific risk” of the girl being “very seriously injured or killed” after her mother began living with Khazma could have been identified at the time her case was closed.

“Nevertheless, in my view, it can be established that DB’s situation at the time of case closure involved potential danger, which had been inadequately assessed and acted upon,” she said. “DB was left unsupported.”

According to the findings, the DCJ accepted it “missed numerous opportunities to protect” the children and “did not respond with appropriate urgency and skill to consistent information” that they were in danger.

Grahame said while she was extremely critical of DCJ’s work with DB and her family, she was not blind to the difficulties experienced by child protection workers.

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She said major reform was “urgently” needed, and acknowledged reports last year from the NSW Ombudsman and Auditor-General, who said the system was “inefficient, ineffective, and unsustainable”.

The inquest heard DCJ has commenced addressing some of the key recommendations. DCJ has been contacted for comment.

In a statement to the inquest, DB’s brother remembered his sister had followed him everywhere like a shadow.

“She looked up to me, and we loved each other very much,” the boy said. “We would run through the hallway and meet in the middle to hug each other and laugh.”

The coroner said one day, if he chooses, DB’s brother will be old enough to read the findings.

“I offer him my sincere personal condolences and acknowledge his strength,” Grahame said. “I am sorry we were unable to keep him and his sister safe.”

Khazma is eligible for release on parole in December 2049.

If you or anyone you know needs help, call Lifeline on 13 11 14 (and see lifeline.org.au), 1800 RESPECT (1800 737 732), the National Sexual Abuse and Redress Support Service on 1800 211 028 or Kids Helpline on 1800 551 800.

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