TWO days after toddler Tanilla Warrick-Deaves was beaten, whipped and left for dead, a caseworker from NSW Family and Community Services visited her mother's home.
Tanilla was in her pram, unconscious and dying, but the caseworker didn't bother to lay eyes on the little girl.
No report was filed about her condition, and two days later she died.
It was perhaps the most disgraceful example of what is described by Tanilla's devoted stepmother Brooke Bowen as a systemic, chronic failure by FACS to protect the vulnerable two-year-old despite evidence of extreme abuse and neglect.
Tanilla's stepfather Warren Ross was ultimately found guilty of murder and sentenced to 40 years' imprisonment. Her mother Donna Deaves was sentenced to 12 years for manslaughter.
In the wake of her death it was also widely expected a coronial inquest would be announced, and expose how FACS systems failed to protect Tanilla.
Yet almost six years on, Ms Bowen said FACS had still not been held to account for its failings. And she was recently told an inquest was now unlikely go ahead.
FACS's own internal review into the death of vulnerable children identified there had been 24 reports relating to Tanilla since 2004 and numerous interventions and risk assessments had been carried out, including regular visits by caseworkers. Despite this, Tanilla's safety was never secured.
That review made seven recommendations designed to improve FACS processes.
But Ms Bowen said the review was never made public and its recommendations have remained a secret.
"They never gave us the review to read because they said it breaks the privacy of the caseworkers," Ms Bowen said.
"Now a child's lost her life, and I think it's very important that we and the public know what changes have been made in the system since Tanilla's death. How are we meant to know that it's not going to happen again?"
She said there had been 34 welfare reports made on Tanilla since 2004.
Ms Bowen conceded the mother and stepfather's primary responsibility in Tanilla's death but questioned why there was no effective intervention.
"I feel the caseworkers need to be scrutinised and it's wrong that's getting shoved under the carpet," she said.
"They were getting reports of a child being bashed.
"That poor little girl was two years (and) eight months old and her body was that badly bruised she was unrecognisable. She was robbed of her life."
In a statement the State Coroner's office said the case was also investigated by the Ombudsman's Child Death Review Team which identified "further opportunities for improvement" beyond the internal FACS review.
"The Ombudsman also made a Special Report to Parliament which dealt with the systemic weaknesses and improvements that had been identified in cases like Tanilla's," a spokeswoman said.
"With the assistance of the Crown Solicitor's Office the State Coroner reviewed all of this material and considered whether anything further would be gained by convening an inquest.
"The State Coroner was conscious it is not the role of an inquest to publicly blame or shame individuals for failings rooted in systemic weaknesses.
"Further, he noted the inadequate responses to Tanilla's needs had occurred prior to, and during, 2011 and significant improvements and mechanisms for monitoring these issues has now been put in place.
"On that basis, it was determined an inquest was not in the public interest."
For Ms Bowen, that response simply isn't good enough.
She said the failure to conduct an inquest was protecting a "broken system".
"There has been a number of children (who have) died after Tanilla," she said.
"How can they say the system has changed when it hasn't?"
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