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In March 2017, the death of a baby boy “known to child safety” sets in motion a frantic few days.

Television cameras and uniformed police camp outside the old weatherboard and tin house in Yeppoon where five-month-old Justin* sustained “catastrophic head injuries” while in the arms of his father: an intravenous drug user with a history of paranoia, alleged child abuse and domestic violence.

The man tells police he fell while holding the infant and landed on top of him. Detectives doubt the explanation; they treat the matter as a possible homicide.

Child safety officers find records showing serious concerns were raised about the boy two months earlier but never formally investigated. “Mad as hell” politicians in Brisbane point fingers about what went wrong.

Then the case of baby Justin disappeared.

There were no more news reports; no more recriminations about broken systems. The police did not lay criminal charges, despite autopsy evidence of extensive and “highly suspicious” injuries to the child in the weeks leading up to his death.

The police investigation was inconclusive but the coroner declined to hold an inquest.

Last year Guardian Australia’s Broken Trust investigation revealed serious failures in several domestic violence linked-deaths that were not properly investigated by police and overlooked by coroners.

The investigation has now uncovered new and previously unreported evidence about child deaths, including the case of baby Justin.

Internal documents reveal that the police sent a child protection detective to investigate concerns about Justin two months before he died but information about the visit to the family home was not entered into police systems. Police did not inform child safety authorities.

Guardian Australia has spoken to child safety workers, police, witnesses and experts. Sources with direct knowledge of the case, and a former police officer who has reviewed documents, say they have significant concerns and questions about why the central Queensland coroner has never held an inquest into the baby’s death.

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‘Flinching every time I went to touch or hold him’

On 10 January 2017, an anonymous notifier sent an email to child safety authorities about Justin. The email alleged that the boy appeared injured and had been unwell for more than three weeks.

“He has [visible] injuries on his face such as cut lip, bruised forehead and bruised cheek,” it said. “Child is severely underweight and parents have commented about never having money for food or nappies. Generally not clean or hygienic.

“[Justin] seems to be flinching every time I went to touch or hold him.

“Both parents … drink, smoke and take drugs and the children aren’t being looked after properly.”

The child safety department conducted an initial assessment that mandated that an investigation should begin within five days.

But the department only opened an investigation on 6 March, almost two months later. By then Justin was on life support in hospital.

According to a “systems and practice review” conducted by the child safety department, the “the incapacity of the department to respond within the recommended response timeframe resulted in the identified concerns not being addressed or mitigated for Justin”.

The review also found the boy’s death was not the result of “action or inaction” by the department.

To those familiar with the case, that conclusion is a “whitewash” and an “exercise in excusing serious failures”.

A child safety employee who was involved in the case said department staff “all knew this case was going to end up in front of a coroner”.

“It was just months after the death of Mason Lee and it felt like there was this intense scrutiny on everything we did. And then nothing happened. I still don’t understand why there was never an inquest.

“I don’t know what happened … I don’t understand how child deaths just disappear.”

The child safety department said it was not legally able to comment on individual cases but that “the safety and wellbeing of children and young people remains our highest priority”.

It said the department had “robust reporting and accountability oversight bodies”.

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Criminal history

Records seen by Guardian Australia indicate Justin’s father had an extensive criminal history including convictions for drug offences, fraud and breaking and entering. He was jailed for repeatedly breaching domestic violence protection orders against a former partner, including a threat to kill the woman. He also pleaded guilty to assaulting a police officer although no conviction was recorded.

Child safety had previously removed children from his care, including after one case that involved allegations he had locked a child in her bedroom and assaulted her. When asked about the man by child safety officials, the girl soiled herself, the records state.

Child safety documents indicate that Justin’s mother presented to hospital for an abortion with Justin’s father when she was 15 and he was 23. She identified the man accompanying her as her “cousin” but her social media posts from the same time refer to him as her “boyfriend”.

The family was understood to be transient while the mother was pregnant with Justin, including living at caravan parks.

In October 2016, soon after Justin was born, police were called to a disturbance at the Yeppoon house. A witness later told police that they had seen the boy’s father hit the mother across the back of the head with a baseball bat.

The same witness said Justin was rarely seen outside the house.

After the anonymous child safety notification on 10 January 2017, the department spoke to staff at a childcare centre that Justin attended twice a week.

They said they had queried bruises and other apparent injuries but the mother had said they were caused by older children being rough with him.

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‘Not good with follow up’

Because the notification from January 2017 included allegations the boy had been physically harmed, the child safety department also notified police. A detective from the child protection investigation unit was sent to the house to conduct a check on 11 January.

After Justin died, police could find no formal notes or records about the visit.

A child safety officer emailed police on 6 March – the day Justin died – trying to find out more details about the potentially critical interaction, which was the only time any public official had seen the boy before his death.

Did the detective record anything about letting child safety know the outcome of his visit?

“I serious[ly] doubt it, [he] was not good with follow up,” a police officer replied via email.

The child safety officer asked politely again. Her manager wanted to know: was there any way of checking?

“No there isn’t. Let them know that I believe we did not advise you [at the time] of the outcome of that inquiry.

“Unless someone called to ask [him], but I can’t see him following through with you.”

The officer in question had resigned from the Queensland police service only days beforehand.

Police later told child safety they had obtained more information – that the officer who attended had no concerns; that the child was asleep and that the officer had decided not to wake him to conduct a more thorough check.

Police records show officers attended a domestic violence call to the family home two days later, where they found Justin’s mother covered in blood after breaking a locked window to access her car keys. She was labelled the “respondent” – or primary perpetrator of violence – by police.

It is unclear whether those officers accessed records that would have detailed the father’s history of violence.

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‘I get angry really quick and over nothing’

In late February, Justin’s father phoned a public mental health service.

“The chemistry is messed up in my head … paranoia is fucking sky high right now,” he told the counsellor. “I get angry really quick and over nothing.”

He denied thoughts of harming himself or others but said he kept weapons in his house for protection.

The man had previously been diagnosed with an antisocial misconduct disorder, trigger schizophrenia and a “cluster B” personality disorder.

Kate Pausina, a former detective with expertise in reviewing domestic violence-linked deaths, said the case appeared to be an example of “a perfect storm” of failures and multiple missed opportunities to intervene.

She said three departments – child safety, police and the health department – each held information that could have prompted urgent action to protect Justin.

But there were missed triggers – including child safety’s failure to begin an investigation, and police failures to record details – that might have prompted the case to be looked at by a “suspected child abuse and neglect” team that enables information-sharing between agencies.

“The QPS and other agencies have, again, been conveniently relieved of scrutiny over their failures in protecting the safety of our most vulnerable members of society,” Pausina said.

“The have again not been investigated, scrutinised or held accountable in providing a transparent account of their failures – failures in adequate investigation of child harm [and] record keeping …

“Government departments responsible for ensuring the safety of children and women breathe a collective sigh of relief that the media have not pursued the case, or that families do not have the support or resources to raise further questions.”

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‘Highly suspicious for non-accidental injury’

Justin’s father told police he had been carrying the boy on the evening of 5 March 2017 when he slipped on an unknown item. He told police he had fallen down an internal step and that the infant was between him and the floor as he landed.

Justin had consumed half a bottle of milk and then fallen asleep, he said. He had called an ambulance about four hours later when the boy awoke and appeared to be struggling to breathe.

Justin died in hospital from what the pathologist described as “catastrophic head injuries”.

His autopsy also found significant other injuries – which did not cause his death – but which the pathologist said were “highly suspicious for non-accidental injury”.

These included a broken left femur – at the top of the leg – that would have been at least a few weeks old.

“It would have required severe force to fracture a femur,” the pathologist said.

Justin also had fractures to 17 of his ribs – which would have been more than a week old – of the sort typically caused by a “compressing or squeezing type force”. These could not be accounted for by the fall described by his father.

The boy’s weight – in the bottom 3% of children his age – was labelled “suspicious for neglect”.

The pathologist said the autopsy could “neither confirm nor exclude” that the head injuries that caused Justin’s death were caused by the fall described by his father: “It is possible that the above-described incident could have caused these injuries.”

No charges have been laid – either for the death of Justin or in relation to suspicions he was subject to abuse or neglect. Police would not respond to questions about how their investigation was finalised and the child safety documents seen by Guardian Australia do not refer to the latter stages of the police investigation.

But in an earlier email a detective outlined the nature of the investigation. He said medical and forensic evidence had raised “considerable doubt” about the father’s version but could not rule out a fall. More evidence would be needed “to charge anyone with homicide”.

Gathering evidence about Justin’s pre-death injuries would be a lengthy process. In both cases, police would need not just to show Justin was harmed but to identify who had harmed him.

“This can be near impossible as we are unsure how many incidents there are,” the detective said. “We will also unlikely know who had access to [Justin] during his 5 months of being alive.”

He said police would also investigate the parents’ responsibility to provide medical attention.

In a statement, the Queensland police service said detectives had conducted “a full and thorough investigation” into the death of a five-month-old boy at Yeppoon on 6 March 2017.

“At the conclusion of the police investigations, the matter was referred to the coroner,” it said.

“Should members of the public have any further information in relation to this matter they are urged to contact police.”

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No response from coroner

Guardian Australia does not suggest Justin’s parents should have been criminally charged over his injuries or on the basis of neglect or in connection with his death.

Pausina reviewed the information Guardian Australia was able to obtain and – while noting she did not have access to the records that document police decision-making about whether to lay charges – agreed that the investigation would have required additional or new evidence to justify a homicide charge.

But she and child safety workers with knowledge of the case say they have concerns that the coroner with carriage of the case did not hold an inquest.

Guardian Australia requested a copy of the coroner’s finding four months ago. The coroner with carriage of the case, David O’Connell, had not responded to that request at the time of publication.

The QPS said it had referred the matter to the coroner and that the finding had noted “that if further persuasive information is made available then the coronial investigation can be reopened”.

A police spokesperson said a referral to the QPS ethical standards command was triggered “if a coroner determines that further QPS reviews are required”.

“These systems and processes are critical in ensuring that when tragedies occur, the QPS can learn from them, and make changes to better serve the community.”

A spokesperson for the coroner’s court said coroners did not comment on cases and “speak through their findings and rulings”.

“It is inappropriate for coroners to add to or detract from what they have said other than as part of their findings.”

Pausina said the lack of an inquest to establish how a five-month-old baby sustained previous fractures and subsequent fatal injuries “reinforces the victim’s lack of importance in our society”.

* Name has been changed

• In Australia, domestic and family violence counselling is available from Full Stop Australia on 1800 385 578. Other international helplines may be found via www.befrienders.org.