Over three quarters of an hour, a 13-year-old girl who has bounced around the child protection system since she was a baby steals some car keys, assaults her carer and takes off in a Holden Commodore. She does not get far.
Police try to stop her but do not give chase, stopping and watching on as she slides off the road at almost 150km/h, smashing into trees and dying on impact.
The girl was living at an Ipswich residential care facility, her 14th separate out of home placement in a short and troubled life.
Queensland's Child Death Case Review Committee reviewed her April 11, 2012 death, on Kruger Parade, Redbank, finding "the actions and inactions of the service system were linked to the child's death".
Following an inquest into the death in 2015, State Coroner Terry Ryan found the evidence did not support that finding, but did note "many deficiencies" in the child protection system relevant to the girl's life.
He recommended changes to ensure kids with complex needs could not access cars, a reexamination of how often care facilities called the police and a review of the Department of Communities Child Safety guidance on restraining.
It is one of 18 "child protection" deaths investigated by Queensland coroners in the 2015-16, all of which identified shortcomings.
The Coroners Court of Queensland's most recent annual report, tabled in State Parliament on Monday, notes problems with finding, assessing and responding to risks before all of the deaths.
Multiple agencies or people had information that, in hindsight, could have helped better judge risks and improved interventions, the report states.
Highlighting problems with information sharing, a massive over-reliance on self-reporting and failure to gather extra information, the coroner finds overstretched resources were blamed in almost half of all cases.
The report argues agencies responsible for child protection failed to understand patterns of abuse and needed to be better equipped to step in earlier.
"This is particularly salient with respect to the long-term impact of childhood exposure to domestic and family violence, irrespective of whether the child was physically hurt during a reported episode of violence," the report states.
The coroner reviews child protection deaths as part of its Domestic and Family Violence Death Review Unit, building on the Queensland Child Death Review Process.
Other concerns highlighted in the annual report include Queensland's suicide rate (almost 14 per cent of reportable deaths) remaining above the national average and a lack of reporting of coercive and controlling behaviours in the lead up to domestic violence murders.
Controlling behaviour was apparent before 42.7 per cent of the 238 murders by family members from june 2006 to January 2016, with stalking noted before 14.5 per cent of them.
"However, in a substantial proportion of cases subject to a review by the DFVDRU, these coercive controlling behaviours were not reported, or not recognised as acts of domestic and family violence," the report reads.
"... In these circumstances, a lack of recognition of the increased risk of harm associated with this type of abuse may mean that victims who express concerns or seek support are not being provided with appropriate assistance.
"And perpetrators who exhibit these behaviours, are not being held accountable for their controlling tactics, by the services and agencies required to respond."
The coroner also notes a need to better study links between between domestic and family violence and suicidal threats and attempts.
