Kumanjayi Johnson was born 15 weeks early in June 2021, spending over four months in Darwin Hospital.
He was diagnosed with cerebral palsy, global developmental delay and hydrocephalus and also suffered from hearing and vision loss.
His mother, who led a transitory lifestyle, was unable to meet his complicated care needs, so orders were made for him to be taken to what is now the Northern Territory children and families department.
Delivering her findings into the child's death this week, NT Coroner Elisabeth Armitage found the department failed to actively prioritise contact between the child in care and his biological family, culture, language and Country.
"Although Kumanjayi's parents were unable to look after him, they loved him," she said in her report.
The child was placed with a foster family in October 2021 and stayed with them for the rest of his life, receiving "exceptional care".
On June 6, 2024, Kumanjayi fell ill and was taken to Palmerston Regional Hospital where he went into respiratory arrest and died, despite all efforts by staff.
Judge Armitage found he died of sepsis, a reaction to an infection causing his immune system to harm healthy tissues and organs.
The coroner found that in the two-and-a-half years Kumanjayi was in care, records indicate he only spent time with his mother on three occasions, the last potentially organised by his carer, not the department.
"Facilitating time between Kumanjayi Johnson and his parents and other adult family members is an express legislative obligation," the coroner said.
She cited legal requirements to ensure contact between a child in care and their parents, wider family, kinship group and, if an Aboriginal child, the right to enjoy their culture, language and Country.
"Despite the legislative requirements and the internal guidelines, the department failed to adequately advocate, plan for and coordinate Kumanjayi Johnson's connection with his family," the coroner found.
She noted the department agreed it ought to have supported Kumanjayi's mother, a domestic violence survivor with an alcohol problem and transitory lifestyle, to help her maintain contact with Kumanjayi.
The mother was caused further distress at the mortuary when she wanted to touch him one last time but was told she could only view him through a glass window.
The coroner recommended that the department introduce a metric in monthly reporting that measures family contact and, in the case of Aboriginal children, access to Country.
The department should also ensure efforts are made to build relationships with parents of children in care and support them to ensure ongoing connection to family and culture for a child.
The coroner also recommended the NT government design and fund a fit-for-purpose viewing and bereavement facility at Royal Darwin Hospital mortuary.
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