A NSW coroner has directed 17 recommendations at several organisations after a five-year-old was drowned by his mother in the Murray River in 2017.
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The mother was found not guilty of murdering the boy and of the attempted murder of his brother in the NSW Supreme Court by way of mental illness.
An inquest in Deniliquin in May last year examined 28 key issues focusing on the organisations and agencies the mother was involved in, and potential shortcomings and inadequacies.
Coroner Teresa O'Sullivan in Lidcombe Coroners Court on Friday said the child was clearly a much-loved younger brother and adored by his grandparents.
"He was described as full of life from an early age, loved to play games and attend the local park ... very outgoing and always carried a toy truck or ball," Ms O'Sullivan said in delivering her findings.
She said the loss continued to be felt by family members and the wider Deniliquin community.
"It is hoped that from the inquest process, some small measure of solace comes in the form of information, answers and agency accountability," Ms O'Sullivan said.
She concluded that the boy died at about 6.15pm on March 2, 2017 due to the acts of his mother, and made 17 recommendations.
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They are directed to NSW Police Commissioner, Victoria Police Chief Commissioner, the NSW Department of Communities and Justice, Murrumbidgee Local Health District and the Catholic Education Office.
The Deniliquin mother, then 27, had taken her two sons aged five and nine to the Murray River at Moama, and across the border into Echuca.
The undisputed evidence at her Supreme Court trial was she caused the death of her youngest son by holding his head underwater and drowning him.
According to the judgment, she made a concerted effort to do the same to her older son, and he came close to dying but managed to free himself and escape.
The woman's mother had reported the trio missing earlier in the day.
Her daughter had spoken to her on the phone on the day of the incident.
"Don't worry about coming and getting us, you will never see us and the boys again," she said.
The woman had believed her two boys were in mortal danger.
She believed the kinder fate for her sons was to drown them.
The sentencing judge noted the mother had heard voices in her head and used methamphetamine and cannabis which had worsened her mental health.
In closing the inquest the coroner offered her sincere condolences to the late child's family, saying his grandmother displayed enormous dignity, courage and strength in giving evidence.
The coroner urged the NSW Commissioner of police to make changes, including to the force's apprehended violence order procedures and reports of welfare concerns.
Changes have also been recommended for Victorian officers.
The incident could be used by police and emergency dispatchers for training purposes, Ms O'Sullivan said.
- with Australian Associated Press
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