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Teegan Rose Hayes was born healthy in Devonport, Tasmania, in October 2011. Twenty-four days later, she died. The state's child protection service did not know she existed until she was in intensive care, even though it had been receiving reports about her family since 1997.

Fifteen notifications were made before she was born. Thirteen were closed at the first stage. In 2018, Coroner Olivia McTaggart found that Teegan's death was accidental, caused by suffocation while she slept in her mother's arms. She also found that it could have been prevented if child protection had properly assessed and acted on the warnings.

This episode follows the notifications one by one, from a paediatrician's concern about a toddler to an anonymous call three months before Teegan's birth. It looks at cumulative harm, at what happened to the file after her death, and at the findings of the service's own review.

For professionals, the episode draws out six practice strands: closing notifications at the front door, cumulative harm, reliance on self-report, assessing parents with intellectual disability, the unborn baby, and what a service does after a child dies. It ends with six reflective questions.

This episode discusses the death of an infant. Details are kept non-graphic. There was no inquest, so the episode draws on the coroner's written finding and news reports, and it says where information could not be found.

Hosted by a social worker with more than fourteen years of industry experience.

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