“In the most significant cases, some employees should have had their employment terminated.

“We would have expected that some other officers would have received a reduction in pay, and others demoted.”

Five frontline officers received a “reprimand” meaning they were spoken to by a manager and three others quit before action could be taken against them.

Despite finding punishments were inadequate, no further action can be taken against staff who had already been disciplined based on the principle of double jeopardy.

Mr Setter said only one employee, referred to as Manager 1 in the coroner’s report, was identified as not having been previously disciplined.

The report made three recommendations including allowing the watchdog to commence a disciplinary process against Manager 1 and to launch a new investigation into more senior officers for” their role in the management of resourcing and workloads”.

Any time the child safety department plans to discipline a public servant in the next two years, independent legal advice must be sought from Crown Law.

Child Safety Minister Leanne Linard accepted all recommendations and said the department had reviewed processes since Mason’s death.

“I think it is important to say that the department has learned a lot through this experience,” she said.

Ms Linard believed none of the staff “got off scot-free”.

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“It has been understandably a painful experience for people who are called in their professional lives and act every day to protect children’s interests.

“It has been laid bare that in this respect we have failed so I think it is not true to say that anybody got off scot-free, I think that it has had a profound personal impact on everybody who was involved.”

Department of Children and Youth Justice director-general Deidre Mulkerin said most of the child safety officers dealing directly with the family had left the department.

“About 21 staff were involved in Mason’s case from taking a phone call right through to close case work with the family.

“Some others have move onto other roles, some are no longer in direct frontline roles.”

LNP child protection spokeswoman Amanda Camm said there must be accountability.

“We owe it to Mason Jet Lee and the other children who have died on this government’s watch since we first learned how badly the system failed the 21-month old boy.”

An audit report released last year found Queensland’s child safety system was “struggling to cope” with the number of reports it receives and was not adequately structured to meet the needs of some of the state’s most vulnerable people.

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